Why do babies die at homebirth? You may be surprised.

Intensive care.

More babies die of infection at homebirth than at hospital birth.

Surprised?

Homebirth advocates often insist that homebirth is beneficial because it avoids exposing babies to infections. That claim always made little sense on its face since the major infectious causes of neonatal death, group B streptococcus and herpes, are found in the mother’s vagina. Now a new paper by Grunebaum et al. confirms that the high death rate at American homebirth includes an increased risk of death from infections that would have been easily prevented or treated at the hospital.

Homebirth increases the risk of neonatal death from infection.

The paper is Underlying causes of neonatal deaths in term singleton pregnancies: home births versus hospital births in the United States.

The authors note:

Midwife-attended home births in the United States (US) are associated with an increase in adverse neonatal out-comes such as a higher incidence of neonatal mortality (NNM), Apgar score of 0 at 5 min, and neonatal seizures or serious neurologic dysfunction, but the causes for the increase in NNM in home birth have not been reported previously. The objective of this study was to evaluate the underlying causes of NNM in midwife-attended home births and compare them to hospital births attended by a midwife or a physician in the US.

What did they find?

Overall, the midwife-attended home births had the highest rate of neonatal deaths (122/95,657 NNM 12.75/10,000; RR: 3.6 (95% CI 3–4.4), followed by hospital physician births (8,695/14,447,355 NNM 6.02/10,000; RR: 1.7 95% CI 1.6–1.9) and hospital midwife births (480/1,363,199 NNM 3.52/10,000 RR: 1)…

Among midwife-assisted home births, underlying causes attributed to labor and delivery caused 39.3% (48/122) of neonatal deaths (RR: 13.4; 95% CI 9–19.9) followed by 29.5% due to congenital anomalies (RR: 2.5; 95% CI 1.8–3.6), and 12.3% due to infections (RR: 4.5; 95% CI 2.5–8.1).

By and large, labor and delivery issues refer to oxygen deprivation from a variety of different sources: inability to perform a timely C-section through inability to perform an expert neonatal resuscitation. It’s only to be expected that most of the deaths at homebirth are attributed to not being at a hospital.

Congenital anomalies as a cause of death is also an expected finding since that is the major cause of death for term babies in hospitals.

But the fact that infection is the 3rd leading cause of death at homebirth thoroughly debunks the claim of many homebirth advocates that a key benefit of homebirth is avoiding infections. You don’t avoid neonatal infections by giving birth at home because the infectious agents are in the mother’s vagina, not the hospital environment. The difference in infectious deaths at home vs. the hospital is because hospitals prevent infections by prophylactic antibiotics for group B strep and elective C-sections for active herpes.

The results are represented by this graph:

img_1377

The authors conclude:

Our study shows that the significantly increased risks of neonatal deaths among midwife-attended home births are associated with three underlying causes: labor and delivery issues, infections, and fetal malformations. Each of these underlying causes was significantly increased when compared to midwife-attended hospital births.

The hospital NNM in our study is similar to the NNM reported for 2010 in the US by Matthews and Mac-
Dorman. This study’s significantly elevated term NNM of 12.75/10,000 births for home births confirms
the increased neonatal mortality risks reported among midwife-attended home births by other US home birth studies: Cheyney et al. reported a NNM of 12.3/10,000 from 2004 to 2009 and Grunebaum et  al. reported a term NNM for home births of 12.6/10,000 from 2006 to 2009.

They note that homebirth is much more dangerous in the US than in other industrialized countries:

Other studies on homebirth outcomes such as studies from the Netherlands, Ontario and British Columbia, where homebirths are well integrated in the health system, found no increased risk of adverse perinatal outcomes for planned home births among low-risk women …

American homebirth midwives (CPMs and LMs) lack the education and training of all other midwives in the industrialized world including US certified nurse midwives (CNMs) and midwives in the Netherlands, the UK, Canada, Australia, etc.

American homebirth kills babies. Avoiding the hospital doesn’t merely increase the risk of a baby dying from oxygen deprivation; it also increases the risk of a baby dying of infection.

  • fishcake
  • Daleth

    OT: Did anyone see this? “According to information from the Los Angeles County Coroner released today, the stroke that killed 34-year-old model Katie May in February was caused by ‘an injury sustained during a ‘neck manipulation by chiropractor.‘”

    She was a single mom. Her daughter is seven years old.

    https://www.yahoo.com/style/m/90bb5246-5896-32cb-8a82-208094c0a5ad/ss_34-year-old-model-katie-may.html

    • demodocus

      Orac wrote about it yesterday

    • guest

      I know someone who survived a chiropractic-created arterial dissection, and her life will probably never be the same. A mutual friend who is a chiropractor just got butthurt that the person started telling everyone about how it was the fault of the chiropractor (who adjusted her both before AND AFTER she started showing dissection symptoms!!), and got very huffy about how “not all chiropractors, and she shouldn’t have done this, and shouldn’t have done that”. I hadn’t put it together ’til now, but it’s exactly what NCB types do to loss-mothers and birth-injured mothers that question why NCB failed them. Exactly. I’m kind of chilled, really. She now adjusts infants too, and children. I hope she never kills anyone.

      I also won’t let a chiropractor touch me ever. I don’t care how many people like their work, I’ve met and heard about so many that are so wooish I refuse, especially since I could most likely get better care from an actual physical therapist.

      • The Bofa on the Sofa

        got very huffy about how “not all chiropractors,

        Did you respond with Bofa’s Law?

        🙂

        • guest

          Haha, sadly no, this was almost 8 years ago and I hadn’t found this site.

        • Felicitasz

          Please help me with this: what is Bofa’s Law? 🙂

      • Sean Jungian

        I will never see a chiropractor. As far as I am concerned, they are woonatics of the first order.

        I understand they can be *somewhat* helpful when it comes to lower back pain, but I will stick with seeing a PT or masseur for that should the need arise.

      • Mishimoo

        My father has stress fractures, bulging discs and some deterioration as well as general wonkiness; he was told by a specialist that he needs surgery, which he is probably still trying to avoid. When we were still on speaking terms, he called me because he had found this miracle working chiropractor who “is perfectly safe because he ordered x-rays and saw all the issues before he started physically adjusting my back!” and we ended up in an argument because I maintain that physical manipulation of a spine which is falling apart is unethical.

        • mabelcruet

          I suffered from long term neck pain caused by work-using a microscope means you extend your neck whilst looking down and lots of pathologists either get neck pain or low back pain. At the same time, my (now) ex had low back pain. I went to see a proper chartered physiotherapist but my ex insisted a chiropractor was better. My physio took a full history and examination, no x-rays because he said it was clear from his exam that it was scalene muscle problems and not bone, and then I had 3 sessions of treatment. He gave me exercises to do, and at the end of the 3 sessions I was cured-he said I didn’t need to come for follow up and if did the exercises that should keep it under control so unless it flared up again, that was me done. Total cost-less than £150. My ex, meanwhile, had seen the chiropractor. He had taken loads of x-rays, all of them pretty crappy, either under or over exposed, or malrotated. Even before he’d examined my ex, he told him that he would need at least 3 sessions a week for a couple of months, them 2 sessions a week, then weekly manipulation basically indefinitely-total cost, probably £1000s. Obviously an utter scam and a license to print money if you have gullible patients. I’be never had a repeat of my neck pain to the same extent, and never needed to go back to the physio. My ex, meanwhile, is still handing over wads of cash to con men.

          • Mishimoo

            Sounds about right! My father was given a similar treatment regime, and thought I was silly for simply checking in with my GP every so often. It reminds me of the difference between a proper dietitian and the nutritionists some of my friends swear by. The dietitian I saw flatly stated that there’s not much she can change with my diet because it’s pretty healthy except that I should try eating a bit more hard cheese and try exercising more to help shift the last few kilos, whereas the nutritionists my friends see provide a really restrictive diet plan with supplements only they sell.

      • fishcake

        Friends took their newborn (their first child) to a chiropractor weeks after she was born. When asked why that was necessary, they said something like “to fix her up after her rough birth.” Definitely worry about them.

        • Erin

          Multiple members of my family think I should be doing more to help my son come to terms with his traumatic birth.

          We went to a Halloween Party today (with chocolate, crisps and costumes) and either all his peers also had traumatic births or toddlers pretty much all behave the same regardless.

    • Sue

      Many Chiros are claiming that the people already had the arterial injuries, which is why they were presenting for treatment of neck pain.

      To this, I can only respond (with intentional shouting): IF YOU CAN’T EXCLUDE THAT SOMEONE WITH NECK PAIN IS PRESENTING WITH AN UNDIAGNOSED ARTERIAL DISSECTION, YOU HAVE NO BUSINESS ADJUSTING THE NECK. EVER.

      • Daleth

        EXACTLY!!!!

      • corblimeybot

        I said this same thing to a few people defending chiropractors in comments sections discussing this poor woman. They got themselves into a bit of a tailspin trying to claim that chiropractors are valid medical professionals, while simultaneously claiming that they aren’t required to know when it’s completely inappropriate to screw with someone’s neck.

  • Sue

    Great article.

    So many people misunderstand the source of pathogenic organisms. The vagina is both the source of those miraculous bugs that people worship for seeding the newborn gut, and also the pathogens that infect newborns. In hospitals, patients with resistant organisms are on the surgical and medical wards and ICU, not in the rapid-turnover labor/maternity wards where healthy women are moving through over a couple of days.

  • guest

    Why would I be surprised that more babies get infections when born in homes of average cleanliness than in hospitals that have strict sanitation and sterilization requirements for the entire building?

  • The Computer Ate My Nym

    It’s interesting to me that the rate of death due to congenital malformation is higher for homebirth midwives versus physicians in the hospital (though significance is not apparently tested) and definitely significantly higher for homebirth versus hospital midwives. I wonder if some of the CM that cause death at home would have been survivable in the hospital.

    • An Actual Attorney

      Some of the numbers may come from “pro lifer abortions.” Give birth with no care available, and if the baby dies, it’s God’s will,not a choice you made.

    • blueyedtexan

      Could be because some of them are also turning down testing of any kind. I have read a lot on natural birth boards of women declining even a single US and all blood testing because it starts the “cascade of interventions” before the woman is even in labor :/

    • Montserrat Blanco

      It might be the case that when a couple knows their child will have serious congenital problems they might choose homebirth, keeping the baby comfortable and spending all their short lives in their parents arms instead of at a hospital with lots on interventions, pain and maybe a slim chance for some years of life with important disabilities. I would not jump to a conclusion with just that observation.

      • swbarnes2

        I’ve heard that mentioned as a possibility, but how many people want to live in the house where their baby died? I read an account once of a”successful” homebirth that included an episiotomy, and the woman was traumatized by that. You give birth at the hospital, you mourn, and then you don’t have to see the room where it happened ever again.

        • Clorinda

          Sometimes the hospital will put you back in the same room for a subsequent baby. You just hope they redecorate so you aren’t quite so aware.

      • The Computer Ate My Nym

        You could do that in a hospital too. A hospital is not going to demand aggressive treatment of a newborn who clearly has a slim to nil chance of survival, especially if survival, if it happens, is likely to be associated with very poor quality of life. Keeping the baby warm and comfortable and saying goodbye quietly is an entirely reasonable option for the hospital birth of a severely malformed newborn. (Though the people going for homebirths in this situation likely don’t realize that.)

        • Clorinda

          We were asked specifically with our baby. We knew beforehand and the hospital was willing to go far as we wished them to within reason to extend his life for as long as we desired. They would have gone to SOME aggressive things but it would only have been live extending in order for say a relative living far away (or spouse or child staying far away) to have a chance to get there to meet the baby if he was born while they were away. As it was, we held a tube of oxygen near his face and that may have helped him stay alive for 5 hours. Because it was a scheduled c-section, most of the extended family was able to come while he was alive and see him, which is something we wanted.

          Another thing that hospitals are beginning to provide are comfort cots. New technology (or at least refined technology) that provides a cooled cot so that a stillbirth or even some miscarried babies can be kept with the families a little longer because it prevents the bodies from deteriorating quite so fast. You wouldn’t get that chance at home.

          • Sharon Campbell

            I wish that my parents had had that option with my little brother who died after 30 minutes. I donated my wedding dress to a group that makes burial clothes for these babies in his name. I feel really good about that!

  • Felicitasz

    Surprised? YES, I am. Does home birth equal no screening here in the US? Once again my surprise comes from my own Canadian story (planned homebirth ending up in a hospital transfer and then c/s so I got to know the full range of care :S ) – I got tested for Group B strep and herpes and bunch of other lab stuff before getting the go-ahead for my home birth plans.
    This blog is really very informative; I am learning how many different meanings the expression “home birth” has. Wow.

    • Heidi_storage

      Home birth in the US means you have a “provider” with, probably, no actual medical credentials, and most likely no risking out criteria.

    • Azuran

      Someone who does a home birth with a CNM will probably have about the same care you did. They follow standard of practice and will require prenatal care and testing to make sure the mother is low risks and can birth at home. And should transfer at the first sign of complication.
      A CPM works totally outside of the system. It’s basically like going to a faith healer instead of a doctor. In general, they work for women who aim for the ‘natural’ and feed their fear of medical intervention. Many of them will have no prenatal care of any kind and some will never risk out anybody.

      • The Bofa on the Sofa

        Someone who does a home birth with a CNM will probably have about the same care you did.

        I wouldn’t count on it. Yes, in general, CNMs have better training than CPMs (almost goes without saying). OTOH, the CNMs that do homebirths tend to be on the fringe. Most CNMs won’t do homebirths because they are aware of and appreciate the risks involved. The CNMs that are doing homebirths are typically either not aware of the risks, or dismiss them. They are doing it because they are zealots.

        That’s not something you want from a provider.

    • Sean Jungian

      It almost seems as though CPMs (not the CNMs) take riskier pregnancies as more of a challenge and refuse to risk anyone out.

      • AA

        One CPM said she’d like love it if one of her “hardcore homebirthers” wanted to deliver twins or breech at home.

        • Sean Jungian

          I remember that. Horrifying.

        • RudyTooty

          Oh, I’m sure there’s more than one CPM who feels this way.
          CERTAIN. 100%. They love this kind of *in your face* “we’ll do our high-risk birth at home and plaster it all over the internet and proclaim it NORMAL.” They love it. See Google for evidence.

      • RudyTooty

        I would argue that it doesn’t *seem* this way, but that it is this way. Often a woman will become too high risk for CNM care in a hospital, and then seek out a CPM or LM for a home birth. And CPMs will take them. Because many risk factors that medical professionals consider dangerous, CPMs see as ‘variations of normal.’

        Conditions that I have personally witnessed where clients have transferred *INTO* a CPM’s practice:

        Breech presentation at term
        Advanced maternal age
        Hx of Multiple cesareans.
        Multiple gestation – twins.
        Obesity requiring extra antenatal testing
        Rh sensitization

        I’m only providing anecdote. But I rarely witness CPMs refusing to care for clients. Unless there are strict laws and regulations forbiding it, they will find a way to provide care for all kinds of crazy high risk conditions.

        That said, even if they (CPMs) stuck to lowest-risk only, they’re still up sh*t creek without a paddle when they encounter a true obstetric emergency in a home setting or birth center setting.
        So naturally, their outcomes are poorer.

  • MaineJen

    It’s quite telling that “labor and delivery” problems account for the majority of homebirth deaths, while at the hospital it appears they’re not as big a factor. Perhaps doctors know more about labor and delivery than CPMs after all?

    • swbarnes2

      Or if labor is going badly, the OB says “screw it, C-section stat”. The homebirthing midwife can either admit defeat and start the lengthy process of transfer, or they just keep on, and hope the problem magically fixes itself.

  • DelphiniumFalcon

    OT: sorry for the reduced activity but I did end up having that partial nephrectomy and good thing too because it was a clear cell renal carcinoma. I’ll know more in Feb when I go in for more scans and genetic testing but so far it looks like they got it all and it was very early stage.

    But the real reason for the off topic is Vickie Sorensen, the Utah midwife involved in the early delivery of twins and the death of one twin is finally on trial as of October 17th. Details are still sparse but it’s finally happening.

    • Roadstergal

      Wow, glad to hear it was successful!

    • Dr Kitty

      Glad to hear you are through the surgery, and that things are looking good.
      Best wishes for a speedy recovery and all good news.

    • KeeperOfTheBooks

      Best of luck with the testing, and glad to see you around! 🙂

    • BeatriceC

      I’m glad to see you back! Hoping for nothing but good news in February.

    • momofone

      Glad to see you! Hoping for all good news!

    • Mishimoo

      Hope you’re healing up well and only have good news in February!

    • The Computer Ate My Nym

      Glad you got it taken out and hope for good news in February!

    • MI Dawn

      Glad it was taken care of and you are in recovery stages. Hoping for excellent news in February for you!

    • Azuran

      I’m glad everything went well. I hope your recovery goes well and that the testing turns out ok.

    • AA

      Vickie Sorenson also possibly had twins (of her own) but lost one during a planned OOH birth. You can see the Internet trail in that she was asking midwives about the “REAL risks” of waiting to go into labor spontaneously beyond 38 weeks, then her gofundme said that one of the twins died and they needed money for, among other things, emergency transport. It’s possible that it was a helicopter transfer to another hospital–but also possible she was laboring at home and then things went bad.

    • Montserrat Blanco

      I am really happy to see that you are doing well. Best wishes.

  • lawyer jane

    Do these numbers assume that none of the deaths due to congenital anomolies could have been prevented if in a hospital?

  • lawyer jane
    • Platos_Redhaired_Stepchild

      WTF? These are the Abstinence Only chickens coming home to roost in our nether regions.

    • Guest

      A lot of it is in older adults, older baby boomers and younger traditionalists. They were never really taught about STD prevention, and divorce/dating/sleeping around as an empty nester and in retirement communities is becoming more common (or at least STDs in these populations getting spread are becoming more common).

    • Montserrat Blanco

      In Spain I got syphilies testing as standard of care when I got pregnant during the first trimester. I had performed a STDs test before trying for a pregnancy, everything came back normal. But at least here every pregnant woman gets STDs testing as standard of care.

      I have to say that I have never been on the Abstinence Only army, just used condoms for a very long time and with most of my sexual partners I always used condoms. It worked well for me.

      • demodocus

        i got STDs testing too, as part of my providers standard proceedures, but you need to get prenatal testing, and not everyone does

      • lawyer jane

        Sadly the babies getting congentinal syphillis probably never had any prenatal care at all. I can’t remember the exact stat, but the rate of babies born with no prenatal care at all went up 2-3% in the past few years where I live! It seems that even with Obamacare we still have a big problem with access to health care. This likely fits in to the increasing maternal mortality in the US.

  • Mel

    I’m trying to think if I’ve ever heard a home birth advocate worry about neonatal infection in the hospital….

    I know that they’ve freaked out over maternal infections but I don’t remember ever hearing about being worried about the infant.

    That’s not actually a comforting fact in my mind; it signals to me that home birth advocates seem to think neonates are tiny, bomb-proof, super-people instead of tiny humans with relatively under-developed organ systems and the physiological reserve of a piece of wet tissue paper in a hailstorm.

    • namaste863

      Or they just don’t give a shit.

    • Cody

      They do worry about that. That is the entire purpose of avoiding as many vaginal exams as possible.

    • Roadstergal

      That’s definitely something I’ve heard trotted out often from US and UK homebirth-advocacy friends.

    • Tori

      ‘Wet tissue paper in a hailstorm’ — I like that analogy!

    • Felicitasz

      I know I was very worried. For my baby, not for myself, that is. MRSA and other hospital superbugs were one set of nightmares, and all those people, visitors etc. with their everyday colds and whatnot. From this angle, I definitely would have preferred my own bedroom, combined with my group B strep and herpes free vagina 😛

      • corblimeybot

        Not a great way to find out if you aren’t really free of group B or herpes, though.

    • mabelcruet

      But why would they worry? These are birth warriors with babies coming earthside via the stars! And then there’s always the good old douche with Hibiscrub that’ll make everything shipshape…

    • corblimeybot

      One of my friends cited this as part of her reason for having a homebirth, in part because her first baby had an infection when the baby was born. Baby got this infection from mom being in labor for a very long time with broken water, which persisted because she refused the recommended c-section. So it’s hard to see how the situation would have turned out better if she’d labored at home with the first baby. Possibly it could have been worse, since no one would have been there to give the baby the antibiotics the baby received.

  • CSN0116

    I always wondered what these women, who often also forego all prenatal screenings, do when they inadvertently give birth with an active infection or to a baby with major physical abnormalities that need immediate attention. Now I have my answer.

    I was group b positive with my final pregnancy. My labor progressed fast and I was worried about getting enough bags of antibiotics! I came in proclaiming my status and the need for the drugs to be started immediately lol. In the end, I got what we needed and all was well.

    • MaineJen

      Ever see that episode of “19 Kids and Counting” where that one daughter who became a “midwife” helped deliver the baby with omphalocele? Yeah, they had no idea that was coming.

      Side note: I was also group b strep for my second pregnancy, but she came too fast for me to get the 2nd bag of antibiotics. 🙂 She was fine luckily. I’m sure many who have homebirths have no idea of their group b status, as it certainly doesn’t cause any symptoms. Scary…

  • Amy M

    This may seem obvious/ignorant, but I imagine the reduced NNM by congenital anomalies for hospital midwives, is that many of the anomalies are detected prior to labor and the pregnancy then overseen by a high risk OB? So the rate of women giving birth with CNMs to babies with congenital anomalies is lower to begin with.

    • MI Dawn

      You’re correct. As a CNM, high risk patients (anomalies, multiples, uncontrolled diabetes) were risked out of our practice and turned over to the Maternal-Felal Medicine docs. So our NNMs were extremely low and the MDs were much higher.

      • guest

        I used a CNM group who did do multiples (at least twins, I don’t know about higher order), but there were additional requirements: You must give birth in the hospital and you must also see an MFM throughout the pregnancy.

        • MI Dawn

          You’re right, and I should have been more explicit. We could handle vertex/vertex twins, IF they were term and no pregnancy complications for mom, with MD in house. But it was pretty rare for us to see twins at all. I can only remember 1 set, tbh.

      • Daleth

        Yes, I got risked out of my in-hospital CNM practice because I was carrying mono-di twins. I think they would have been able to do di-di twins though, but maybe only with OB oversight.

    • guest

      Almost certainly correct; CNM’s see CNM-risk-level patients, and do not see risked-out patients unless they’re seeing them in a home setting (rare, but does happen) where an OB and a medical facility are not “in” on what’s happening with the health of the mother or baby.

      It also explains the OB mortality rate being double the CNM rate; OBs see higher risk patients.