If you’re a reader of Grounded Parents or the Skeptical OB, you’ve likely seen the recent guest post by Jamie Bernstein, Dr. Amy’s responses, and the hundreds of heated, emotional, intelligent, not-so-intelligent, and everything in between comments on both blogs.
Early on, the debate hinged mostly on the interpretation of statistics. I’m not here to re-do anyone’s calculations or to side with one statistical interpretation. Not because I can’t do the calculations (as one of the commenters on the Skeptical OB put it, “Is there NO OTHER Skepchick who can math?”) Yes, lots of us can math. For real. But while I would consider myself relatively knowledgeable about life science and genomic data and am really into crunching those types of numbers, I have the wisdom to know that my unrelated profession/hobby, while really science-y, does not make me an Obstetrician, social scientist, or statistical expert.
To paraphrase Jamie’s stance, the relative risk of death from homebirth for low-risk mothers is very small, and the sample sizes too minute to derive a meaningful comparison to hospital births. Essentially, the cohorts are not fairly comparable. Dr. Amy asserts in her typical, callous way that her analysis is correct, and that the absolute risk of death at homebirth is manyfold higher than at hospital birth. Several commenters vehemently contend that one or the other is being a grossly misleading jerk. I stopped reading the comments early on for fear of the quicksand/whirlpool/quagmire that frenzied comment sections can become.
Dr. Amy asked Jamie to correct her math, and for Grounded Parents to apologize. While Jamie did revise her error, I am not going to comment on whether or not she did it correctly. I will say that Skepchick Network is not a hive mind, and therefore none of us can apologize on anyone’s behalf regardless of our stances on the topic. It has been made clear in both the comments and the back channels that we have differing notions on this and most issues.That said, I would like to address Dr. Amy and her readers, and Grounded Parents readers directly. Why not just add a comment to the threads? Because I have been an avid Skeptical OB follower since after my daughter was born. I also love writing for Grounded Parents. The dissonance is interfering with my ability to sleep, so this is an endeavor of catharsis.
Here goes. I am a staunch opponent of anecdata. I’m also a lover or Walt Whitman, so I’m going to go ahead and contradict myself by responding emotionally with my story.
I am almost certain that the beautiful baby girl in the picture above, my firstborn, would have perished or been left with dire health consequences if I had attempted a home birth. I was perfectly healthy, in good physical shape, exercised often, and was as low-risk as they get. My water broke on the due date before contractions started, and so we attempted in vain to rest, and finally headed to the hospital. After waiting for 8ish hours with nary a Braxton-hicks in sight, we decided on a Pitocin induction. After stalling out at 4 cm, I got a wonderful epidural and dilated to 10. By this time, it was almost seventeen hours after membrane rupture. For me, pushing was so much more painful than any of the contractions, and the epidural was no longer helping. I continued to push, and it was absolutely excruciating. In the meantime, my temp started rising. After almost two hours of this, baby had barely budged, and was showing signs of fetal distress. I was a wreck. Maybe I’m weak, but I thought I was going to die. At this point, my doctor strongly advised a forceps delivery, and I agreed. To this day, my husband recounts his horror at seeing the size of the evil, gleaming, claw-like forceps. Let me tell you, no epidural could block out that level of pain. As I screamed bloody murder, my angelic nurse told me to get myself the hell together. With a push from me and the skilled surgeon wielding the forceps, my daughter emerged into the world (with barely a scratch on her head) and directly to a massive team of medical professionals. My first sight of her is forever etched in my mind. Her nostrils were triangular. Her hair was thick and black. She had a double nuchal cord and a true knot. It turns out I was unknowingly pushing with little to no slack in her cord. I was so traumatized by the pain that, in that moment, I barely wanted to look at her. Perhaps the awful birth experience contributed greatly to my postpartum OCD/anxiety/blues amalgam (along with my predisposition to this type of thing). Still, we bonded fine, I breastfed her for 14 months, and, for now, we are the loves of each others lives. She loves to hear the story of the doctor pulling her out of mommy in a moment of adventure and chaos, while her little brother was simply pushed into the world with relative ease. I wouldn’t have had it any other way.
Maybe a stronger version of myself in another universe was more successful and pushed her out at home with a midwife, and that version of baby A was fine. In yet another universe, I attempted a home birth, I couldn’t push her out, and she didn’t survive the hospital transfer. Who knows? I do know that in comparison, my second delivery was a piece of cake à la mode. Baby J would have been fine at a home birth, although I would have dearly missed out on the wonderful care we received at the hospital for the next two days, as well as a decent epidural, among other things.
So back to the conflict at hand. Maybe the sample sizes skew interpretations. Yes, there are myriad factors that confound the numbers. I have no doubt that Jamie Bernstein is being as objective as she can, and that her heart is in the right place. And perhaps, as Jamie says, Dr. Amy is “calculating relative risk by using two completely non-comparable data sources in order to scare readers away from homebirths.” I’m remaining agnostic on this, and not because anyone is compelling me to. I will say that Dr. Amy is one SOB. Her harsh persona was arguably a necessary evil to thrust a previously under-visible issue into the spotlight. Some say that she’s too harsh, even insensitive and cruel. I agree, I don’t always like her tone, and feel that at this point, her less-than-kind front undermines her message (and I say “front” because I don’t think she’s a mean person). Nonetheless, I admire her devotion in trying to prevent the suffering caused by even one more unnecessary homebirth death. Because when someone’s baby dies at home, those parents don’t feel like a data point. I have no doubt that Dr. Amy’s heart is in the right place and that her motives are transparent.
Confounding factors aside, if you’re a risk-averse individual like me, then go with a hospital birth. Not because Dr. Amy says it’s safer. Not even because the data suggests it might be a little bit safer. But because even if you’re low-risk, something could go wrong. And if it does, data and statistics aside, you’ll 100% want to be at a hospital. If you’re not extremely risk-averse, and you want a birth experience in the comfort and familiar environment of your own home, that is totally up to you. You’re an autonomous, sensible individual, capable of making your own informed decisions. Until, of course, you have a newborn.
All images, © 2014 Kavin Senapathy
“(and I say “front” because I don’t think she’s a mean person)”
Amy has mentioned that her on-line persona is much different from her real life one, and that she adopts the extremely harsh tone for the reasons that you surmised. Unfortunately, it provides and avenue of ad hominem attack for her opponents, but if the only argument they have is “She’s so meen”, then you know she’s doing well.
I agree with everything about this post: homebirth probably is a bit more dangerous but the way to show it is with a carefully controlled study and not by comparing apples and oranges. The Skeptical OB is generally right about things but kind of a jerk at times.
And I am super glad I had my kids in a hospital, because of my own anecdata: my first was very “low risk,” but was born with meconium in her lungs, and a lot of it. There was no way to know about the mec until after my water broke. Once we saw that ugly green color, the hospital had a team standing by to resuscitate her as soon as she was born, with an initial APGAR score of 4. She spent 3 days in the NICU on IV antibiotics to bring down her fever.
Maybe everything would’ve been fine if we’d been at home and transferred to the hospital, but maybe I wouldn’t have given birth that day at all without the pitocin, and the infection would’ve gotten worse with us never knowing about it…
Also our newborn screening test came back positive for a genetic disorder that needs immediate treatment. On the treatment, she’s fine, but it was important that we knew within a couple of days. So for anyone who does give birth at home — get your newborn screening test done and sent out for analysis right away please! It is not okay to put that off.
Your last paragraph actually scares me almost more than homebirth with the anti-medicine crowd – which I understand is not representative of all home birth folks, but there’s a lot of overlap in those consentric circles. Even if a woman gives birth at home safely, if the underlying reasoning is a distrust of the medical establishment, then those screenings and that immediate treatment isn’t going to be forthcoming.
You bring up a very interesting point. There are a few home birth studies from Britain or the Netherlands that show outcomes not drastically worse than hospital birth, but they all involved solid, thorough prenatal care and screening. If women are choosing home birth because they want to avoid the medical establishment as much as possible, then those outcomes are going to be terrible, especially if they also reject proper care for their newborns.
**There are a few home birth studies from Britain or the Netherlands that show outcomes not drastically worse than hospital birth, but they all involved solid, thorough prenatal care and screening. If women are choosing home birth because they want to avoid the medical establishment as much as possible, then those outcomes are going to be terrible, especially if they also reject proper care for their newborns.**
Yes. The other big difference between the UK/Netherlands and the US is that they only let REAL MIDWIVES work as midwives. Look up the difference between a CNM (Certified Nurse Midwife–that is, an RN with a master’s degree in midwifery) and a CPM or LDM (depending on the state, qualifications can be and often are as low as a high school diploma, one written exam to pass, CPR training and a letter from a midwife stating that you have accompanied her to at least 50 home births).
It’s a very big difference!!! And every homebirth midwife in the UK and the Netherlands–or I should say, every midwife who is practicing legally–is the UK/Dutch equivalent of a CNM. They do not let crunchy high school grads learn CPR and start calling themselves midwives!
I may as well be more specific in case anyone really does read this who has their doubts about the necessity and urgency of the screening.
My daughter has PKU, a disease which causes protein from ordinary food sources (including breast milk) to produce toxic byproducts when it is eaten so that eating normal foods actually causes brain damage. Babies start off completely healthy, but as they eat more and more protein over the first year of life, irreversible brain damage can be done. Before the introduction of newborn screening, PKU was the cause of a large number of severe intellectual disabilities. These days babies are identified by abnormal blood test results on their newborn screening, and are treated by being fed a diet which is low in natural protein and higher in an artificial protein which does not have the toxic effect (and sometimes eventually given a drug which improves their ability to break down natural protein — this has allowed my daughter to have a more normal diet).
Even a week or two of breastfeeding or regular formula can cause irreversible damage for people with severe PKU, and the newborn screening is the only way to detect it before the damage is done.
There are many other diseases which are tested for by the newborn screening these days, but based on my experience, the possibility of PKU by itself should be reason enough to make sure that the screening gets done and done quickly. My husband and I had no idea we were carriers for this genetic condition until our daughter was born.
**I agree with everything about this post: homebirth probably is a bit more dangerous but the way to show it is with a carefully controlled study and not by comparing apples and oranges.**
That’s a puzzling comment, since the Cornell study that Dr. Tuteur/Skeptical OB discussed is apples to apples. It compared (among other things, but I’m focusing on the apples) three things:
(1) midwife-assisted homebirth of a full-term, normal-weight baby,
(2) midwife-assisted birthing-center birth of a full-term, normal-weight baby, and
(3) midwife-assisted hospital birth of a full-term, normal-weight baby.
In other words, it compared midwife-assisted low-risk births in three different settings. They were low-risk because the babies were full term and over 2.5kg (5.5lbs), and because any competent midwife, hospital-based or otherwise, will “risk out”–that is, send to a hospital OB–anyone who’s high risk (I just got risked out myself because I’m expecting monochorionic twins).
And on top of that, the Cornell study compared ALL such births over a three-year period… not a midwife-selected subset of births.
Conclusion? Low-risk, full-term, normal-weight babies were more than FOUR TIMES as likely to die in homebirths than hospital births. And twice as likely to die in birthing centers, BTW.
Here’s the study, and then here’s a link to Skeptical OB’s post on it:
http://www.ajog.org/article/S0002-9378%2813%2901155-1/fulltext
http://www.skepticalob.com/2014/02/new-cornell-study-shows-homebirth-has-4x-higher-death-rate-than-comparable-risk-hospital-birth.html
And upon comparing those
I think you’re mentioning something we should stress more: birth is inherently risky and it can be very traumatizing without anybody making a mistake, or being mean, or being a jerk.
But pregnancy and childbirth have been romanticised so much that people try to find somebody to blame when their perfect birth experience turns into a nightmare.
Right on, Giliell. I’m glad you took that away from this post. Childbirth circumstances are usually out of one’s control. My birth was horribly traumatic, but I’ll never be anything but thankful for for those who participated and gave me my healthy baby.
Thanks Kavin! This is exactly the type of conversation I was hoping to spark and I’m not sure how it ended up where it ended up. I also personally agree with everything you said. It is my personal opinion that in the lack of good data, it’s probably best on issues this important to err on the side of worst-case-possibility. I would not personally recommend homebirth and think that anyone considering homebirth should consider the possibility that there could be an elevated risk, even for people in the subset of low-risk births. Saying that, I know that some women could have needs that may be met by homebirth and if they exist in that low-risk subset and understand the possibility of elevated risk and are doing everything they can along with their OB and midwife to reduce that risk, I understand why that decision may be right for them.
I would like to address “needs* that could have been met by homebirth.
The only *needs* met by homebirth are psychological. Pyschological needs are certainly important. However, they are far overshadowed by the physical needs in an immediate life or death situation. Injections hurt and can be traumatizing, as proven by the number of people who fear needles. But vaccinations still do more good than harm, which is why hospitals require staff to all get flu shots and public schools require most students to have standard vaccinations.
Since so many others are speaking from personal experience, I’ll just jump in with mine. I have a diagnosed phobia of medical environments. It is so severe that years ago before I received a lot of therapy and learned and practiced many coping techniques for dealing with my phobia, I had difficulty just visiting my father in the hospital after he had heart surgery. When I say I have difficulty, I mean classic severe anxiety attack symptoms such as losing the ability to speak, shaking or even convulsing, being unable to make eye contact. I once had such a bad anxiety attack while driving to the hospital to get a routine MRI that I got lost and had to stop by the side of the road and do some calming exercises just so I could recognize where I was. No doubt I developed this phobia for the same reason many people don’t like doctors/hospitals – because hospitals are associated with pain, disease and death. I understand how scary hospitals can be. With phobias, if the phobia is of something that can be avoided, often therapists will just recommend avoiding it. But I can’t avoid medical care! So the next best treatment is facing our fears and overcoming them. I had to do that while pregnant. I learned biofeedback techniques, and had therapy sessions, and I found ways to make myself get all the necessary bloodwork and ultrasound, vaccinations, and ultimately surgery necessary to make sure I was safe and my two kids were born healthy. It would have been so easy for someone with my phobia to buy into the rhetoric of natural childbirth. Probably the only reason I didn’t was because I’ve been immersed in a culture of skepticism my entire adult life.
A good percentage of women who attempt homebirth will end up being transferred to the hospital. At the birth center I attempted to give birth at (which ONLY took low risk candidates and was staffed by CNMs) 20% of the mothers transferred and 10% ended up with c-sections. During my prenatal care, the CNMs insisted that I visit the hospital and become familiar with it BECAUSE of my phobia. They realized that if I ended up in the 20%, transferring to the hospital while in the throes of labor, that that would be even more traumatic than if I had planned and prepared to give birth at the hospital. If someone is having a homebirth because they have serious and irrational fears about hospitals and medical environments, homebirth is possibly not a good option because it could leave them even less prepared for the hospital transfer that has a 1 in 5 chance of happening.
There is a hierarchy of needs. In a perfect world we could meet all the needs of everyone. Maybe some day in the far far off future we’ll live in that world. But in the meantime, oftentimes lesser needs must be sacrificed for more important needs.
I’m glad that your birth centre had such good policies. I think that for all women anxiety and fear can be dramatically reduced by such policies. Many things are best discussed and understood before women ever have the first contraction.
My CNMs made sure I knew the facilities and medical personel who was likely to be involved. That is something we can work on within the system of hospital care
How perfectly sensible! You’re absolutely correct. Even for those with an intense phobia of doctors/hospitals, it makes most sense to *plan* to give birth in one.
I just wanted to address the issue about the “only” needs being met being psychological – the thing is, the whole process of birth is deeply interconnected with psychology, you can’t really separate the two without causing problems (physiological & psychological). The complex actions of hormones & neurotransmitters that unfold in an uninterrupted physiological birth are strongly influenced by the psychological state of the mother; it is well known, for instance, that anxiety interferes with the normal process of birth, and that calm, dimly lit environments help labour to progress. The move towards the increasing popularity of homebirth stems mainly from a recognition of this fact; a straightforward birth is more likely when the mother feels comfortable, relaxed & in control, which for many women is at home (though of course the opposite is true for some women, who feel far more secure & relaxed when they know that doctors & medical equipment is just round the corner). Personally I have no anxiety issues with hospitals but I chose a homebirth because I knew I could do more to create the optimal conditions for a natural birth at home than in hospital, I had an uncomplicated pregnancy and I felt confident in my body’s ability having already had 2 babies. I also live within reasonable distance of 2 major hospitals, so knew if I needed to that transferring to hospital would be easy. As it turned out I did transfer after 12 hours of labour (failing to progress, baby’s head wasn’t engaged, waters hadn’t broken & I was 18 days “overdue” so the midwives were being extra cautious) and ended up with a far more medicalised birth than I wanted but thankfully all of the possible risks turned out to be unfounded. It seems my failure to progress may have been due to a combination of excess amniotic fluid, a large baby, and the fact that the one eventuality I hadn’t planned for was a slow labour (having had two previous babies I’d assumed it would be very fast so most of the tips I’d internalised had been about how to slow things down rather than speed things up!). I still think that planning a homebirth was the right decision for us, those first 12 hours were so much better than my previous experience of labour; I felt relaxed, in control, in tune with what was happening, in fact it’s hard to really convey the difference between how a homebirth & a hospital birth feels, really, they are totally different experiences. At home, it felt like it was me doing it, in hospital it felt like something that was happening to me.
I totally agree, though, that for people with serious anxieties about hospital, homebirth shouldn’t be used as a way to avoid confronting those fears because, as you say, they may need to be transferred at an especially vulnerable moment when they are least able to manage those fears and it could be far more distressing, or they may end up refusing urgent medical care based on these fears rather than making a sensible decision. Far better for women to be offered effective psychological help with their anxieties so they can make rational decisions rather than just acting out of fear.
Actually, you know why people are upset beyond what’s appropriate for a mathematical question? Three times today I came across someone quoting that damned study as proof that HBAC is safe! No one here believes that, it’s obviously insane. If I had the courage to look, I could probably find someone trying to use the study to prove that home breech birth is a top-flight idea! (I don’t dare look, I’d have nightmares for weeks.)
If MANA had attempted to use the data to define low-risk home birth candidates, (That is, healthy women, no major pregnancy complications, appropriate testing and monitoring to check for complications, no history of caesarian, at least one prior uncomplicated vaginal birth, single vertex fetus, spontaneous labor between 37 and 41 weeks), and recommended against high-risk home birth, I might have some respect for the article. But they didn’t. They just said, “Hey, it’s safe!”
That’s why it upsets people to hear anything other than a clear, “The conclusion to the MANA study is invalid.” But hey, that’s just my opinion.
But there is good data. I’ll even copy it over since I linked it several posts ago (paraphrased from myself). These all came out in the last year.
“Further, this one paper from MANA is not brand new information…there have been several different kinds of studies, all quite recently, that do have as close to apples to apples as you can get without doing a highly unethical RCT:
https://olis.leg.state.or.us/liz/2013R1/Downloads/CommitteeMeetingDocument/8585
A 2013 comparison at the request of the state of Oregon looking at all hospital and out of hospital births births in the state in 2012 showed a 3 to 8-fold increase in perinatal death depending on the type of out of hospital provider. (3 for CNMs, 8 for non-CNMs.)
http://www.ajog.org/article/S0002-9378%2813%2900641-8/fulltext
2013 study using a standardized certificate of live birth showed a 9-fold increase in a five minute APGAR score of 0 (highly correlated with neonatal death and a good metric for indicating that something is very wrong).
http://www.ajog.org/article/S0002-9378%2813%2901604-9/fulltext
2013 study (unpublished poster presentation at a professional conference) at a hospital that is the primary referral center for therapeutic cooling for neonatal hypoxic ischemic encephalopathy (brain damage due to lack of oxygen at birth) showed a 17 to 31-fold increase in babies presenting hypoxic injury with need for cooling therapy following home birth. The difference is greater when looking at babies being born vaginally, because in the hospital most of these babies in trouble are spotted and a C-section is done quickly.
http://www.ajog.org/article/S0002-9378%2813%2901155-1/fulltext
2014 study using the CDC’s linked birth/death certificate data showed a 3-fold increase in neonatal mortality in home birth attended by a midwife.”
Check them out. Pick them apart if you want. But they all point to home birth as it stands in the US being much riskier than birth in the hospital. They all support at least the low hanging fruit of eliminating non-CNM midwives, standardizing midwife education, care, and risk-out protocols, and integrating all CNMs into the hospital system for more rapid transfer when needed. At which point we can get a lot more accurate data about home birth as it should be versus hospital birth risks and make even more recommendations as needed.
As of now even studies that break out the type of provider to CNM show an increased risk that I am absolutely not willing to take with my hypothetical future baby’s life or brain (or, frankly, my own), and informed choice is seriously hampered by ample pseudoscience downplaying the risks and magnifying the benefits.
This is why I find the demand for more and better data unethical . There already is a lot of data and it frankly doesn’t matter if it’s a two-fold or three-fold increase. I don’t need to know the 7th decimal position. There are lives at stake here. The question isn’t about whethertea with yak butter will soothe your throat more efficiently.
To make a comparison: very few children die because their parents treated them with homeopathy instead of antibiotics. I don’t need to know the exact risk of that happening before I condemn the praxis. One casualty is one too many. Because no matter what the risk for the population is, for the individual there is only 0 or 1.
Right. I’m trying to imagine presenting the data in alli’s comment to an Institutional Review Board and saying, “aaand now we’d like to do a randomized trial and assign pregnant women to either homebirth or hospital birth.” It would be so unethical the IRB would laugh me out the door. I’m also a bit troubled by all this “hey, I’m not a statistician” or “hey this isn’t my area of expertise” all the while dismissing an actual statistician.
I think the key phrase in what you wrote is “home birth as it stands in the US”. As a Brit, I’m frequently shocked by the huge differences in antenatal/intrapartum care in the US vs the UK, it’s like a different world! Here, midwifes are a far more integral part of care than they are in most states in the US, the idea that you would be under the care of an obstetrician for a normal uncomplicated pregnancy & birth would be considered a bit unusual. And because the midwives are highly professional, respected & well integrated into the health care system they generally do a pretty good job & work well with the rest of the system (e.g. things like transferring to hospital from a homebirth are straightforward). Homebirth is now offered as a standard option for all low risk pregnant women and the midwives who attend are experienced hospital midwives who are able to offer women the same standard of care they would expect in hospital (obviously apart from those more specialist things that require a doctor) and who are well trained to quickly spot problems that might require a transfer. I would feel very safe having a homebirth here but might be a lot more hesitant in some states of the US!
Totally agree with your list of “low hanging fruit” as being things that should be a priority if you want to create a system where homebirth is as safe as possible & that until that is done it’s hard to really compare hospital vs homebirth fairly.
“I’m not sure how it ended up where it ended up”
Because you made errors in what you wrote and people are calling you out on them, Jamie. Fix your errors and the discussion will change. People are angry because you have written flat out false things and refuse to fix them, or even address them. This is what people are fixated on and *will* be fixated on until you fix the errors in your posts. They have been pointed out by several people now.
It’s hard to focus on the full message of what you are trying to get across when the details are so full of errors. All you have to do is the right thing: fix your errors. It will be hard to do as those errors are the basis of your “skeptical” viewpoint. But you seem like a very intelligent person, I have faith you can figure it out. Just be honest and truthful.
My wife had two uncomplicated pregnancies with no risk factors or health issues of any kind and our son and daughter were both born health. However during the delivery of our daughter, who was our second child, the last ten to fifteen minutes things very nearly went very very wrong. As I recall the nurse and doctor said something like it will only be a few more contractions and we’ll have a baby and at the next contraction there was a noticeable deceleration in our daughter’s heart rate. This concerned everyone and I noticed the doctor getting a bit anxious. At the next contraction and pushing the head was visible and the birth was almost completed but there was another and more serious heart rate deceleration and I saw the doctor walk over to the wall and make a quick phone call. Our daughter was born at the next contraction and when she appeared and the burse was holding her the doctor started unwrapping the umbilical cord from around our daughters neck, waist, and from between her legs. The girl had clearly been doing gymnastics in the uterus and later I asked the doctor about the phone call and she said that if the birth had not happened as quickly as it had there was going to be an emergency C-section because of the seriousness of the decelerations and the risk of brain damage. I know it’s just our story and only an anecdote, but way better than being a statistically negative outcome.
**The girl had clearly been doing gymnastics in the uterus and later I asked the doctor about the phone call and she said that if the birth had not happened as quickly as it had there was going to be an emergency C-section because of the seriousness of the decelerations and the risk of brain damage. I know it’s just our story and only an anecdote, but way better than being a statistically negative outcome.**
Yes. I’m so glad your daughter is ok. Stories like that are what make me utterly not understand people who plan on a homebirth and reassure themselves that “we’re only 10 minutes from the hospital.” Even if it is just 10 minutes–which obviously it’s not, since it’s much harder to get a woman in the last stages of labor safely into a car and on the road, and ambulances can take a while to get there–that is still more than enough time for irreversible brain damage or death to occur!
Like the author, I think trudging through the calculations again is unnecessary. I would like to point out two more general items.
1. A claim that you cannot even try to do an analysis of this data, because of comparison group issues (basically that there was no built in control group) is a “perfect is the enemy of the good” argument. There is a lot of research that is not double blinded RCT. Some of it preliminary, some population studies, etc. MANA, the CPM/DEM group responsible for this study and data, has made it clear that they want nothing to do with a more rigorous and independent evaluation of their practices. So an analysis using as close a comparison group as possible is the only reasonable option.
2. I realize that Jamie Bernstein is not a reporter and therefore not held to a journalist ethical standards. However, if I were going to write a post critical of someone’s analysis of a topic and I felt there were mistakes, references I could not verify or calculations I could not follow, I would first, if at possible, contact the author and attempt to receive clarification. I realize that, in some cases you might not get a reasonable response or a response at all, but then at least you have done your due diligence. At least per Ms. Bernstein’s original article, there was no such attempt made to contact Dr. Teuter.
Using a recalled product is just a little less safe than using one that hasn’t been recalled. Very few kids are killed by defective products these days, but the deaths are preventable and hence there are recalls. Home birth is defective because it causes preventable deaths, the risks of those preventable deaths cannot be addressed under the best of circumstances (a skilled attendant who does actually deliver low risk patients only). I do not know how the seriousness of this can be understated.
Also absent from the analysis is the recent paper about how the rate of hypoxic brain injury is 18x higher in home births. These injuries are not usually detected until years down the line. Pretending death is the only risk is not fair to people who have been disabled by home birth midwives. I also know of cases where women were stitched up by incompetent midwives and had to suffer through years of surgery to repair fistulas between pelvic organs. Which leads me to my next point….
Also absent from the analysis is the role of lay midwives in this- they routinely lie about the safety of high risk pregnancies and have no accountability for their actions. They are taking on high risk cases and assuring mothers that they will be fine. They relish the chance to attend a breech or a twin or a vbac delivery. When is it really low risk or not? Midwives organizations have declined to define low-risk, despite the recent data showing a very high rate of death for breech and twin deliveries. *Anything* unprofessional that happens won’t be addressed unless you’ve chosen a nurse midwife who is licensed or the rare physician that attends home births.
This is a rather refreshing article after reading Jamie’s 2 previous ones with all the following comments.
The only issue I take is with the final paragraph. Look, women have the freedom to give birth wherever they want. If a woman wants to go squat in the woods by herself, that is totally her choice, and nobody is going to arrest her or charge her with anything if she does that, regardless of the outcome.
The issues are over professional standards of those attending births. They are over legal, medical care. So I just wish in your final paragraph you had been more specific about stipulating that if a woman is low risk, wants to give birth at home and lives near a hospital, and can find an actual medical professional such as a CNM (not a CPM or other type of law midwife) to attend the birth, that’s totally up to her.
We all can’t be medical experts. That’s why we need a medical infrastructure with quality standards that we can trust.
Yeah. Bodily autonomy and informed choice comes up quite a bit in these types of discussions.
On the issue of bodily autonomy, I think pregnant and birthing women should have as much autonomy as any other person, male or female, to make their own medical decisions. But I do not think that extends to expecting medical professionals to provide substandard care, or expecting insurance to cover substandard care, or expecting the state to legalize and license substandard care. CPMs and other lay midwives are the definition of substandard, and should not be recognized, insured, or licensed as care providers, no matter whether women are choosing them.
On informed choice, I absolutely agree that proper standards need to be in place to ensure that midwives are well trained and educated (so CNMs, not CPMs), following appropriate risk out protocols including comprehensive prenatal testing, and integrated into hospital systems to provide relatively smooth transfer, so that the choices offered to women are medically sound and accompanied by real information. If a woman does choose to go outside all of that and ignore risk to hire some traditional birth attendant, a glorified lay person, there won’t be anyone stopping her, but there won’t be anyone in the medical profession supporting her either.
I agree that the issues are over professional standards. It’s unbelievable that lay people can legally attend births. I intentionally left this issue out. I was trying to make the point that even with a CNM or an MD at that, if something goes wrong at home, even with a proper transfer protocol in place, those minutes can make the difference between life and death.
When you say “I was trying to make the point that even with a CNM or an MD at that, if something goes wrong at home, even with a proper transfer protocol in place, those minutes can make the difference between life and death”, I don’t disagree with you factually, but you seem to be implying that even given the highest standard of medical care, no reasonable woman should ever choose a homebirth over a hospital birth. If I am understanding you correctly, then I disagree. (If not, could you clarify?)
ali said, “If a woman does choose to go outside all of that and ignore risk to hire some traditional birth attendant, a glorified lay person, there won’t be anyone stopping her, but there won’t be anyone in the medical profession supporting her either.”
Also, when things do go wrong, as they often do — after all complications of birth are fairly common, the resources to get mom and baby to emergency are an unfair burden. While these kind of emergencies happen outside of planned homebirths, when it is a choice, it becomes such an unnecessary drain on resources.
And while I also agree that it’s still a mother’s right to choose, I agree as well with the plurality here — homebirthing requirements need to be further regulated.
I don’t know about the US stats, but over here (UK) one of the reasons homebirth is being embraced by the NHS is that it is far more cost effective for them than hospital birth, despite the fact that you must have 2 qualified midwives attending homebirths and even accounting for the cost of transfers to hospital. So unless the financial implications work out very differently in the US system I’m not sure your argument about “an unnecessary drain on resources” holds.
It is cost effective for the average person, but those long term NICU and cooling therapy infants might make it more expensive in the long term. Brain injuries can require life long care.
Just wanted to say that it is nice to see this issue being addressed in these comments with nuance and respect! Everything I would have wanted to address has already been said been said by someone else, so… bravo!