Earlier this week I wrote about how Navelgazing Midwife has come to accept some basic realities about pregnancy and childbirth that many homebirth midwives reject. It has been a long time coming.

I first wrote about Barb Herrera, Navelgazing Midwife, almost exactly 4 years ago when she transferred a patient to the hospital so someone more experienced could suture a tear. She acknowledged that she really didn’t have enough experience to suture a tear or insert an IV.

A few months later Barb described her experiences with two births, one a face presentation where the baby would have died without a C-section, the other a serious shoulder dystocia that could have led to the death of the baby. Then she offered surprisingly harsh criticism for another homebirth advocate who questioned the judgment of a provider:

In ignorance, for there is no other way to say it but this, [she] says that whenever a doctor or midwife speaks about induction because the baby is getting large, that that is a threat. Only someone who hasn’t struggled with a shoulder dystocia – either in her own vagina OR with one in her hands as a midwife – would say something so amazingly dangerous…

Once again, she acknowledged that experience had taught her many valuable lessons.

… [W]hen women came to me and said, “I don’t want you to do anything but sit in another room,” I used to obsequiously tell them I would. It is the woman’s birth, after all, right?

Then, with more experience, I woke up and figured out I couldn’t help if I didn’t monitor the mom and baby. It’s not like I’ll do vaginal exams that aren’t warranted or intrude in women’s space, but there are minimums that I feel are necessary for competent care and I no longer will compromise on that belief…

In fact, she went so far as to declare that the reason to hire a birth attendant is because of her experience:

When I am hired to be someone’s midwife, I am being hired as a consultant. I am being asked to share my experience and knowledge, to utilize my skills – the ones that can save a life…

Over the intervening years, NGM has gained more experience and has changed her views based on that experience. That is what a good practitioner does. In fact, she has come to believe that the experience required for certification or licensing as a homebirth midwife is so deficient that homebirth midwives are not safe practitioner. She has put her money where her mouth is, suspending her practice as a homebirth midwife until such time as she has greater education and experience. She deserves kudos for that decision and for having the wisdom and humility to publicly acknowledge her evolving views.

Yet there is a deeper issue here, one that I would like to ask Barb about. There are people out there who have the requisite experience that Barb knows she lacks. We call them certified nurse midwives. And there are people out there who come out of their training with even more experience than that. We call them obstetricians. Those CNMs and obstetricians could have (and probably did) point out to Barb that she did not have enough experience to be a safe practitioner and she blithely ignored them.

In other words, Barb demonstrated the Dunning-Kruger effect. She had so little knowledge on the topic that she couldn’t fathom how little knowledge she had. She had a dramatically over inflated view of her own education and experience. Simply put, she didn’t know what she didn’t know.

It is a problem endemic to homebirth midwifery and is probably inherent to homebirth midwifery. Homebirth midwives disparage experience because they have so little of it. To acknowledge the value of experience would mean acknowledging their woeful inadequacy as practitioners. So here’s my question for Barb:

Was there anything that anyone could have said to you at the time you embarked on your career that would have brought home to you the absolute necessity of copious experience in becoming a safe practitioner? Put another way: Is there anything anyone could have told you to convince you that you didn’t know nearly enough?

If I had to guess, the answer would be “no” because the philosophy of homebirth midwifery disparages the value of experience. And that’s why the homebirth midwifery credential (certified professional midwife) must be abolished. It was created for, designed by, and administered under the auspices of a group of women who have so little clinical experience that they don’t understand the value of clinical experience.

The CPM is a pretend credential for women who want to call themselves midwives but can’t be bothered to (or don’t have the academic skills to) obtain a college level degree in midwifery. It is a pretend credential for women who don’t want to spend the time and energy necessary to acquire the experience that is mandated for all other midwives in the industrialized world.

But maybe Navelgazing Midwife would disagree. Barb, is there anything we could say to homebirth midwives to wake them up to the fact that their education and training is deficient? Is there any way we could convince them of the value of experience?

Since the subtext of the natural childbirth and attachment parenting movements is the notion of the good mother, it’s worth asking what makes a good mother. My whole approach to writing about childbirth and mothering choices is based my rejection of currently popular beliefs about good mothering. Simply put, I believe that good mothering is about choosing mothering and not about mothering choices.

What does choosing mothering mean? It means actively embracing the role of caretaker, confidante, educator and moral guide that mothering entails. It means worrying, planning, consulting, advising and ultimately letting go. Should he be the youngest in kindergarten or wait a year and be the oldest? How should she handle the playground teasing? Am I expecting too much from him or does he have a learning disability? Should I let her go to the dance with the older boy or is she still too vulnerable?

It is kissing the boo-boos, helping them face the fears, stepping aside and allowing them to talk to the doctor in private when they are old enough. It is piano lessons, orthodontia, religious services, holiday celebrations. It is not responding when she says “I hate you” and never failing to respond when you see him teasing another child. It is hard, damn hard, with weeks or months that leave you exhausted or emotionally drained. Yet it is also rewarding at the deepest level, forging a bond to last a lifetime, launching a happy young adult into the world.

It is NOT about specific mothering choices. Breast or bottle? That’s the mother’s choice and nobody else’s business. Natural childbirth? Irrelevant. Baby wearing? It depends on the baby and on the mother. Extended breastfeeding? Meaningless in the long run (and often in the short run, too).

How do we know a woman is a good mother? We know because she cares; she cares about her children and cares about the impact that she is having on those children. To love a child is to choose mothering. In contrast, specific mothering choices have nothing to do with love, because there is not only one way to express love.

My fundamental objection to the philosophies of natural childbirth and attachment parenting is not the emphasis that they place on mothering; I object to the fact that they privilege specific mothering choices over others. In other words, adherents believe their own mothering choices proclaim their “goodness” and that different choices on the part of other mothers identify them as bad mothers.

Instead of viewing mothering as a service they willingly give their children, they view it as a social identity that they construct for themselves, boosting their own egos in the process. That’s why discussions about NCB, breastfeeding and attachment parenting are such a source of discord between women. None of those discussions are about the best way to mother a baby; they’re all about who is the best mother. It may seem like a trivial difference, but it is an immense difference and most women recognize it as such.

The most critical ingredient of good mothering is love. A child who is loved has the advantage over any other child, regardless of the specific parenting choices his mother made. It’s time to acknowledge and value the power of choosing motherhood and stop judging other women based on mothering choices.

This piece first appeared in June 2010.

Time.com has inaugurated a new section called Ideas, and I contributed a piece:

Myths of Natural Childbirth

Barb Herrera, Navelgazing Midwife, has written a series of posts (starting here) on choosing a competent homebirth midwife. In reading the posts, I am struck by how much of what Barb writes comports with what I have written over the years.

I’ve written that homebirth midwives claiming to be “experts in normal birth” is worse than useless. It’s like a meteorologist claiming to be an expert in good weather. If nothing goes wrong, there’s no need for an attendant of any kind. The entire purpose of a birth attendant is to prevent, anticipate, diagnose and manage birth complications.

Barb writes:

But, whomever you’re hiring, it is someone to, ultimately, save the life of you or your baby if a tragic emergency occurs. When a complication occurs in the hospital, there is a team of folks to do the various parts of the job in keeping someone alive. If there are mistakes being made, there is almost always another person there to see it and fix the mistake. In a homebirth setting, you have one, usually two and sometimes three people to save the life/lives. If each person isn’t meticulous in their abilities, there is no back-up team to take over or even witness the mistake/s. This is why choosing the right homebirth midwife is so important.

I have written repeatedly that there are unanticipated life threatening emergencies that can and do happen at homebirth. If a baby needs an immediate C-section or if a baby is born requiring an expert resuscitation including intubation, the baby will simply die at home. The baby will be long dead before the mother and/or baby can be transferred to a hospital.

Barb writes:

It is vital for women and their families to understand that … there are also emergencies that happen in the home that would be able to be handled better and safer if mom and/or baby were in the hospital. If a massive hemorrhage occurs, there are no blood products in the home, nor are there the plethora of means to control bleeding like they have in the hospital. Also, if a baby needs more than minimal resuscitation, the hospital is the place to be for their teams of personnel trained to attend to such emergencies…

I have written that, contrary to the fantasy of the informed homebirth advocate, it is absurd to place responsibility for assuring the competence of a homebirth midwife on the mother herself.

Barb apparently agrees heartily:

… But, how is the client supposed to learn how to be a midwife and be able to gauge whether the interviewees are wise enough to fulfill their promises during their pregnancy – all the while getting care from these midwives? It’s absurd to expect a woman hiring a midwife to know more than the midwife herself. This is where a standardized education and skills system being in place can not only save the pregnant woman time and energy, but perhaps also her life or that of her baby.

Barb moves on to specific questions to ask a homebirth midwife. The questions appear to be designed to differentiate between midwives who follow scientific evidence and midwives who ignore scientific evidence. Although Barb is careful to state that the mother has a right to choose midwives who ignore scientific evidence, it is pretty clear that she does not think much of such midwives.

For example:

I have written repeatedly about the penchant for evidence-indifferent homebirth midwives to insist that any complication is a variation of normal, when it is not. Breech is not a variation of normal, neither is twins.

Barb writes:

Does she say a breech or twin birth is a “variation of normal”? This lets you know she’s on the liberal side of midwives, more amenable to delivering breeches and twins at home. If she is on this side of the spectrum, you might ask these next questions.

* “What is your experience seeing breeches and twins born?” …
* “Have you ever been the primary with them? How many and what were the outcomes?”
* “How did you learn your breech and twin skills?” …

Pre-eclampsia is a potentially life threatening condition for both baby and mother.

Barb points out:

… If you are looking for a conservative midwife, it’s important to know the standard of care is to transfer a woman if her blood pressure is 130/90 or 30/15 above her normal blood pressures. (If your blood pressure is usually 90/56, by the time your BP is 130/90, you could be having a stroke!) If you’re looking for a more liberal midwife, one who doesn’t stick to the rules of what most (medical folks) would consider safe, then knowing her answers will help you here as well. How she answers gives you pieces of the total picture of the type of midwife she is and a decent guideline-roadmap for a normal and inching-out-of-normal pregnancy and birth.

And pre-eclampsia cannot be prevented or treated with diet:

… I guess if you want to know if she’s still of the belief that the Brewer Diet can help a woman avoid or if she has preeclampsia already, the Diet can relieve the condition, that would be good to know, demonstrating she is not an evidenced-based midwife (some of the links have been locked for privacy), despite her possibly saying she is.

Barb is quite clear that, as I have pointed out in the past, friendship has nothing to do with safe midwifery:

… Choosing a midwife is not just about personality meshes. It definitely has elements of that, but it is not crucial to become friends with your midwife. In fact, I’ve found (through my own many mistakes) that not being friends keeps the boundaries clear and allows for decisions to be made autonomously by both provider and client…

In summary, Barb Herrera, Navelgazing Midwife, acknowledges that

• Homebirth has a very real risk of death.
• if certain life threatening emergencies occur at home the baby will simply die.
• The purpose of a birth attendant is to deal with emergencies.
• Midwives ought to be licensed and meet certain minimum standards.
• Breeches and twins are not variations of normal.
• “Liberal” homebirth midwives are indifferent to scientific evidence or ignore it.
• Friendship has nothing to do with safe homebirth midwifery.

In other words, Barb agrees with me.

There is something perverse and dysfunctional about a philosophy that leads a new mother to react with disappointment to the serendipitous rescue of her baby from certain death.

…I dont feel like I gave birth, I feel like he was taken from me…stolen…I dont feel like a mom yet and when Im not holding him I feel like I should still be pregnant.

According to her post on Mothering.com, that’s how Jasper’s mom feels after the emergency C-section that was necessary to save his life.

What happened?

So, last Friday (the 7th) was my 40 week OB appointment, I went in and got settled in for an NST like usual and Jasper ended up having some heart-rate decelerations which concerned my OB …

I got over there and they hooked me up for the NST for about an hour and Jasper had 9 decels, it was terrifying, at one point his heart rate dropped into the 50s.

At that point I was pretty re-signed to an induction, they took me back to a labor room and my OB came in and started the c-section spiel….

During this time my doula showed up and she was shocked too but she also saw the NST results and was very adamant that a c-section looked like the best option …

Did it turn out, in retrospect, to be a necessary C-section? It certainly did. The next day:

Then they told me he had pneumonia….

Turns out he had aspirated some of the meconium and was having some respiratory distress….they were transferring him to the local childrens hospital later that evening and starting antibiotics.

At the children’s hospital on Sunday:

His doctor came in (way young, way cute and way nice!!) and told us what was going on, he was still on dextrose for his sugars but they were weaning him off of that and onto tube feedings.

He was also on oxygen but NOT on a ventilator so that was a good thing, function wise his lungs were a- OK when it came to that.

His respiratory rate was not OK though due to the fluid in there causing him to have to work harder, they had started antibiotics the night before and expected to continue them for AT LEAST 3 more days, possibly up to 5 depending on what his labs look like tomorrow.

Let’s review:

Jasper, for no obvious or anticipated reason, was profoundly oxygen deprived and on his way to certain death (stillbirth).

Through an incredibly fortunate coincidence, his mother had an OB appointment while he was struggling for life.

The obstetrician noted evidence of fetal compromise, carefully evaluated Jasper with an NST and found that he was losing his battle, even before the stress of labor started.

There is absolutely no possible way that Jasper would have been born alive if labor had been allowed to start and continue naturally.

Jasper’s mother clearly understands all of this. She knows that she came within a hair’s breadth of losing Jasper. And yet:

I don’t know how to explain how I feel in regards to the c-section, I dont feel traumatized really…I know it was medically needed for him and it scares me to think what would have happened to him if I had been more stubborn about trying to induce first.

But I don’t feel like I gave birth, I feel like he was taken from me…stolen…I don’t feel like a mom yet and when Im not holding him I feel like I should still be pregnant.

I’m not sure I’m truly depressed at this point but I am frustrated and sad and feeling defeated and helpless.

Only someone thoroughly indoctrinated in the NCB philosophy that privileges process over outcome would have ever contemplated, let alone concluded, that she had not given birth as if giving birth was synonymous with passing through a vagina.

The reality is that this woman hit the jackpot. Despite having a placenta that could not adequately support Jasper, he didn’t die. Through an amazing stroke of good fortune, while Jasper was in the process of dying, he happened to be monitored. Because of that monitoring, his life was saved. It was an incredibly close call. He was so close to death that he aspirated meconium and would have died anyway after the C-section if it were not for the availability of NICU care.

The NCB emphasis on process as opposed to outcome perverts maternal bonding. Instead of enjoying her new baby and basking in her good fortune, this poor woman is reduced to concluding that she hasn’t given birth, and that she should be upset about it.

In my judgment, the essence of mothering is about providing for your child’s needs to the best of your ability. NCB is perverse to insist that good mothering means following a specific performance that ignores the needs of the individual child.

Jasper “told” his mother in the only way he could that a vaginal birth would kill him. Why should his mother feel bad for responding to his plea to protect him from certain death?

I thought Lisa Barrett was demonstrating contempt when she publicly tweeted during the recently completed Coroner’s Inquest convened to examine her role in two homebirth deaths but that pales in comparison to this.

According to a source, Barrett spent Friday evening at a twin homebirth that resulted in one healthy baby and a second on life support and declared brain dead.

I have asked Barrett to comment but have received no response.

addendum 10/14/11: Yes, Lisa Barrett did preside over another homebirth death. The story has just appeared on Adelaide now, aptly titled Inquest midwife Lisa Barrett helped deliver twins, one which later died:

The State Coroner was notified of the death last week of a newborn twin treated at the Women’s and Children’s Hospital.

The Advertiser has learned that birthing advocate Lisa Barrett presented to the WCH with the child’s mother in a taxi.

She had been assisting the mother with a homebirth when complications arose following the delivery of the first child, after which a taxi was called.

Ms Barrett is already at the centre of a coronial inquest into the deaths of Tate Spencer-Koch and Jahli Jean Hobbs during homebirths in 2007 and 2009 respectively.

Closing submissions in the inquest were heard last month and Deputy State Coroner Anthony Schapel has reserved his findings.

During the inquest the court also heard that a coronial investigation was under way in Western Australia regarding the death of one twin during a home delivery in July this year.

The court heard Ms Barrett attended that birth as a doula, not a midwife, and provided a statement to police.

So Lisa Barrett has presided over at least 4 deaths in the past 4 years!

I’ve been writing for years that homebirth is viewed by a homebirth advocate as a piece of performance art with herself as the star. Everyone, midwives, her partner, even the baby are nothing more than bit players in “her” birth. That’s certainly what Marni Kotak thinks.

Eat your heart out Feminist Breeder. Sure you broadcast your homebirth to the world, and you got a corporate sponsor. Nancy Salguiero has gotten lots more attention because she hired a publicist to promote her homebirth. But now poor Nancy, who hasn’t even had her baby yet, has already been eclipsed by Marni Kotak.

… Enter the very pregnant performance artist Marni Kotak, who is transforming the Microscope Gallery into a home-birth center where she will turn the birth of her baby into a work of art… Starting Saturday, she’ll be making the gallery home as she waits for the contractions to start … Then, she’ll have her baby right there with the assistance of a midwife and a doula…

According to Marni:

… I will be completely engrossed in the act of giving birth before a live audience. I will be focused on delivering my child into the world in the healthiest manner possible, rather than on how I look or what the audience may think. Everything I have learned about the birth process is that the more you surrender your mind and don’t try to control the event, but let your body do what it naturally knows how to do, the better your labor progresses. This, to me, provides for the most authentic performance art situation. And the ultimate creation of this life performance will be a living being!

And if that’s not selfish enough:

… her long-term project “Raising Baby X,” … will document her child’s upbringing “from birth through attending college and developing an independent life,” according to her website.

The child psychiatrists out there are already salivating over the patient Baby X will become. Just imagine the therapy sessions:

X (no longer a baby): It seems like my mother doesn’t care about me as a person. She sees me as nothing more than an extension of herself whom she can manipulate for her own ends.

Child Psychiatrist: It’s hard to argue with that assessment since she has used your for her own self aggrandizement from the moment of your birth, deprived you of privacy, and seen you as little more than an art project.

Marni actually claims:

I am driven to hold onto an authentic personal experience in a world that has essentially become consumed by an unreal hyper-reality.

Riiiight, because pushing out a baby in an art gallery in front of a live audience is the authentic experience of indigenous women in all times and cultures ….NOT!

Marni is ever so superior to those women who are immersed in our media driven culture:

… I do feel that people today are desperately seeking a sense of meaning in their lives. Facebook is feeding into that and providing — what I see as an ultimately empty — solution for a hyper-mediated world… Sadly, the more time that people spend on social networking sites and the less time they spend engaging in authentic experiences with friends and family in the real world — and yes, I do still think there is a real world — the more they are denying the significance of their own human experience. This in turn leads to a greater sense of desperation to find meaning in their lives, more wasted hours on Facebook …

Or perhaps to a desire to give birth in an art gallery in front of a live audience.

… And in giving birth in front of the audience, I am showing them, as in my previous performances, that real life is the best performance art, and that, if our eyes can be opened to it, all of the meaning that we seek is right there in our everyday lives.

Or maybe, like many homebirth advocates, she’s just an attention seeking narcissist.

Far be it from me to complain about the participation of trolls in the comment sections of this blog. Trolls serve a very valuable function here. They drive conversation, illustrate various deficiencies in the thinking of NCB and homebirth advocates, and provide endless entertainment.

Every science based website with a comment section has trolls, and they share several important characteristics.

1. Trolls invariably have essentially no education on the topic under discussion. Whether it is anti-vax trolls who have no knowledge of immunology, creationism trolls who have no understanding of evolution, or NCB and homebirth advocacy trolls who lack basic education in science, statistics and obstetrics, trolls literally have no idea what they are talking about.

2. Despite profound and crippling ignorance, trolls generally believe that they are knowledgeable. This is a result of the Dunning-Kreuger effect. As Dunning and Kreuger wrote in their original paper, Unskilled and Unaware of It: How Difficulties in Recognizing One’s Own Incompetence Lead to Inflated Self-Assessments:

We propose that those with limited knowledge in a domain suffer a dual burden: Not only do they reach mistaken conclusions and make regrettable errors, but their incompetence robs them of the ability to realize it.

3. Trolls have a serious problem with scientific evidence; they don’t understand what it is. Contrary to what trolls believe, websites written for lay people are not a source of scientific evidence, long lists of citations copied for those websites are not scientific evidence, and the mere existence of a paper that expresses a particular point of view is not scientific evidence.

4. Trolls seem to be entirely unaware that you have to READ a scientific paper (the whole paper, not just the abstract) before you can declare that it is scientific evidence that supports your point of view. They are also unaware that publication in a peer review journal does not mean that a paper’s conclusions are scientific evidence, merely that the author’s views are worth being included in an ongoing discussion of an issue.

5. Trolls have terrible problems will logical fallacies. They love and frequently employ the fallacy of the lonely fact, the argument from ignorance, and the ad hoc fallacy.

6. Trolls have serious problems with basic logic.

7. Trolls suffer from hubristic self-assessment. Sure it takes a real doctor 4 years of college, four years of medical school and 3-5 years of residency to become knowledgeable about his or her field, but the troll assumes that is for mere mortals. For a troll, reading a bunch of websites written for laypeople is all that is necessary to achieve a level of expertise high enough to advise and criticize professionals.

8. Trolls love conspiracy theories.

9. Trolls are convinced that they are “brilliant heretics.”

10. Trolls are easily frustrated when others fail to recognize their blinding (to themselves) brilliance. In very short order, they start personally insulting those who frustrate them by demanding scientific evidence that they cannot provide.

11. Trolls inevitably flounce. As Skeptico advises in his hilarious Handbook of Woo:

Finally, when you’ve used up all the above tactics, say you’re not going to waste any more time with the [critics] you’ve been debating because they’re too sad, stupid, closed-minded, ______ (insert other flaw the [critic] has) to understand your brilliant arguments. Make a big grandiose statement and exit to start anew somewhere else.

The homebirth statistics keep on coming and they keep demonstrating the same thing: homebirth increases the risk of death.

I’ve written extensively about the appalling rate of perinatal death at the hands of licensed midwives in Colorado, and, of course, the overall US statistics show that homebirth with a direct entry midwife triples the neonatal death rate. The latest data comes from Missouri and the trend continues. Homebirth has a risk of intrapartum death that is more up to 20 times higher than hospital birth.

Birth outcomes of planned home births in Missouri: a population-based study by Chang and Macones published in the American Journal of Perinatology in August 2011 is notable for careful methodology.

… We obtained data from the Missouri live birth and fetal death files that have been linked together by the Missouri Department of Health and Senior Services… The Missouri vital record system is considered very reliable and has been adopted as a “gold standard” to validate other vital statistic datasets in the United States…

Our study sample consisted of women who delivered singleton pregnancies between 36-44 weeks of gestation … Pregnancies complicated by major fetal anomalies and breech presentation were excluded …

The authors divided the more than 800,000 births by place of birth and attendant creating three groups: hospital/birth center births attended by physicians and CNMs, homebirths attended by physicians and CNMs and homebirths attended by non-CNM midwives. (Of note, unplanned homebirths and births attended by non-midwives were excluded.) The groups differed significantly by maternal characteristics.

Women who had planned home deliveries attended by either non-CNMs or physicians/CNMs were more likely to be older, to be white, to have more children, to be overweight and to deliver at greater than 41 weeks gestational age, but less likely to be a Medicaid recipient or unmarried, to smoke during pregnancy, or to have a maternal medical risk factor.

Despite this, the outcomes in the homebirth groups (both those managed by non-CNMs and those managed by physicians or CNMs) had much poorer outcomes.

… [W]e observed that rates of newborn seizures were 4 per 1000 births among planned home births attended by non-CNMs, 0.6/1000 among planned home births delivered by physicians/CNMs and 1.1 per 1000 births among deliveries made by physicians/CNMs in hospitals and birthing centers. The rates of intrapartum fetal death were 0.9 per 1000 births among planned homebirths attended by non-CNMs, 1.7/1000 among planned home births delivered by physicians/CNMs, and 0.1 per thousand among deliveries made by physicians/CNMs in hospitals or birthing centers.

Rates of neonatal death were 1.4/1000 among planned homebirths attended by non-CNMs, 0 among planned homebirths attended by physicians/CNMs and 0.6/1000 among hospital/birth center births attended by physicians CNMs. This difference does not reach statistical significance, however.

After the authors employed multivariable logistic regression models:

… We observed that planned home births attended by non-CNMs remained positively associated with odds of newborn seizures after controlling for confounders. Specifically, the adjusted OR of newborn seizure among births delivered by non-CNMs was more than 5 times as much as the odds in hospital/birthing center births delivered by physicians/CNMs … For intrapartum fetal death, planned home births attended by non-CNMs and physicians/CNM yielded adjusted ORs of 11.24 and 20.33 respectively relative to hospital/birthing center births attended by physicians/CNMs …

The authors conclude:

Our analysis demonstrates cause of concern about safety of planned home births attended by non-CNMs and physician/CNMs. The results of our study suggest that planned home births are associated with increased likelihood of intrapartum fetal death and newborn seizures, despite the fact that the lowest risk women choose this birthing option.

As is the case with most homebirth studies, this study could not separate out home birth transfers from the hospital birth group. Therefore, the study likely underestimates the magnitude of the increase risk posed by homebirth.

The state of South Australia, which includes the city of Adelaide, has published it’s perinatal mortality rates. The data shows that planned homebirth has a perinatal mortality rate more than 17X higher than comparable risk hospital birth.

The report, Pregnancy Outcome in South Australia 2009, is a dry recitation of birth statistics without editorial comment. The statistics are analyzed in every possible way to give a vivid picture of birth in the state. Among the ways the data is analyzed is according to place of birth and the results are surprising and distressing.

Any way you look at it, planned homebirth has a dramatically higher rate of death. The stillbirth rate is higher; the neonatal mortality rate is higher; and therefore, the perinatal mortality rate is higher. In fact, the perinatal mortality rate is more than 17 times higher than that at comparable risk hospital birth! These findings are even worse than the appalling findings from Western Australia, where the data showed that homebirth tripled the rate of perinatal death.

Surprisingly, the perinatal death rate at birth centers was also far higher than the rate at comparable risk hospital birth. Birth centers had a perinatal mortality rate 5X comparable risk hospital birth. This is completely unexpected. Birth centers should have a perinatal mortality rate lower than hospital birth because women with preexisting medical conditions and serious pregnancy complications are concentrated in the hospital group.

Since there were only a relatively small number of planned homebirths, the exact magnitude of the risk is probably smaller than 17 fold. However, the increased risk of perinatal and neonatal death is a remarkably robust finding, extending across time periods and countries and states. To my knowledge, all the existing international, national and state statistics show that homebirth increases the perinatal and neonatal death rates by at least a factor of 3. There is only one exception, a single paper out of Canada; the paper is notable for very strict homebirth criteria and a high transfer rate of greater than 20% in the homebirth group.

There is really no question that homebirth increases the risk of perinatal death. The only people who appear to be unaware of this are homebirth advocates themselves.