There are two main groups of data that anti-homebirth people currently like to bandy about, as “evidence” that home birth produces an excess of preventable neonatal deaths — the CDC 2003-2004 linked birth-death statistics, and (oddly enough), the CPM home birth study for the year 2000 that was published in the British Medical Journal.
First, let’s take the BMJ article. The study authors noted every intrapartum death as well as all neonatal ones; even though intrapartum deaths are included as stillbirths in general statistics. They excluded all infants who died before labor began. There were five intrapartum deaths, including one at the hospital because they ruptured the amniotic sac. Of the remaining four, two were during attempted vaginal breech birth; one was due to “Subgaleal, subdural, subarachnoid hemorrhage” (bleeding in various areas of the brain), although there were no heart irregularities noted with routine monitoring; and one was in a post-term pregnancy, in which the fetus had the cord wrapped around his or her neck six times, and had a true knot in the cord. While Dr. Amy and others insist that home births are only among “low risk” mothers and babies, we see simply from these intrapartum deaths that that is not always the case, because they equally insist that breech babies and post-term babies are not low-risk, which is why they insist that all breech babies be born by C-section (even though Dr. Amy herself says that most breech babies will do just fine if born vaginally), and that pregnancies that go past 41 weeks or 42 weeks (or whatever number they have picked for today) must be induced or sectioned. Of course, placentas do not last forever, and there are some babies who are truly put at risk by old placentas that can’t handle labor; but most babies will do just fine. So, Dr. Amy et. al. are put on the horns of a dilemma — either breech and post-dates babies are low-risk (which belies ACOG’s entire stance on these issues), or not all homebirths take place in mothers and babies who are low risk (which means they can’t just arbitrarily pick the CNM-attended hospital births as an equivalent “matched cohort”).
Going on to the neonatal deaths in the BMJ article, there are nine: three due to lethal congenital abnormality, and six due to other causes, which I quote in full:
Term pregnancy, average labour. Apgar scores 6/2. Transported immediately, died at hours of age in hospital. Autopsy said “mild medial hypertrophy of the pulmonary arterioles which suggest possible persistent pulmonary hypertension of a newborn or persistent fetal circulation…some authorities would argue this is a SIDS and others disagree based on the age. Regardless, infant suffered hypoxia and cardiopulmonary arrest”
Term pregnancy, Apgar scores 9/10. Suddenly stopped breathing at 15 hours of age. Died at five days in hospital, sudden infant death syndrome
Term pregnancy, transport at first assessment because of decelerations, rupture of vasa previa before membranes ruptured, caesarean section, died in hospital two days after birth
Term pregnancy, Apgar scores 9/10. Baby died at 26 hours. Sudden infant death syndrome
Post-term pregnancy, 42 weeks two days age based on clinical data as mother not aware of last menstrual period and refused ultrasonography. One deceleration during second stage, which resolved with position change. Apgar scores 3/2. Brain damage associated with anoxia, baby died at 16 days
Term pregnancy. Mother and baby transported to hospital because mother, not baby, seemed ill, but both discharged within 24 hours. Mother, not baby, given antibiotics by physician a few days after the birth for general sickness. Baby readmitted from home at 16 days because of nursing problems, died at 19 days of previously undetected Group B streptococcus
All of these causes of death happen in hospitals, too, which shows that there is no guarantee that giving birth in a hospital would have prevented any of these deaths. It might have, but perhaps not. I would challenge someone to explain how being born at home causes SIDS (since two and possibly three deaths were attributed to that, even though those two babies had Apgars of 9/10 — and if they come up with some answer, then I will ask them how to account for why it is that in the CDC statistics, there were no cases of SIDS in the home-birth set, but several in the hospital set). Also, I will note that the case of vasa previa (which carries a 50-100% rate of death) was handled precisely as if the woman had not even planned a home birth: the midwife got to the house probably at the same time the woman would have arrived at the hospital in labor; she listened to the fetal heartrate, just like nurses at the hospital would have done upon admittance; she noted decels, which L&D nurses would have noted; they went to the hospital, where they discovered the vasa previa, which is what would have happened in a planned hospital birth (the nurses would have referred the case to a doctor, who probably would have had to travel to the hospital from his practice), and a C-section was performed. The baby died anyway. In the hospital.
Dr. Amy likes to say that all of the intrapartum deaths are actually neonatal deaths, so she intentionally deceives people by calling them that. Unless you look at the data, like I have done (and provided links so you can see for yourself), you would be unaware that these deaths, had they happened in the hospital, would have been termed “stillbirths,” and not “neonatal deaths.” She likes to say that “home birth has a 2.5/1000 rate of death which is nearly three times that of hospital birth!!”, compared to a hospital rate of 0.9/1000 for white term births, but I will demonstrate that this is not an accurate comparison. First, the 2.5/1000 is a crude rate, taking the 14 intrapartum and neonatal deaths and dividing them by the total number of live births (5418). When you exclude the 5 intrapartum deaths and the 3 lethal congenital abnormalities, that leaves 6 deaths, or 1.1/1000. While most of the women in this study were white, not all are, and one of the deaths happened in the non-white group (which statistically has a higher death rate), so excluding those births leaves 5 deaths out of 5418, or 0.9/1000. Just because “know-all, see-all” Dr. Amy predicts zero babies would have died during labor in the hospital doesn’t mean that is the case. Secondly, these statistics do not match risk groups, taking into account things like maternal age, number of previous babies, breech & twins status, etc.
Moving on to the CDC stats, we see a similar picture emerging. In non-hispanic white women, aged 20-44, giving birth to a baby at 37+ weeks of gestation and 2500+ grams of weight, there were 27 deaths out of 25,823, or an apparent 1.05/1000 death rate, compared to a CNM-attended death rate of 0.38/1000. But there were 19 cases of congenital and/or genetic abnormality, many of which carry a near-100% neonatal death rate, even when the problem is known beforehand and everything that could possibly be done for the child is done immediately after birth (and the CNM group includes a few deaths by suffocation and other non-birth-related reasons, which I will exclude). It is possible that some of these deaths may have been prevented or delayed by immediate postpartum care, but in order to determine that, we would have to look beyond the bare statistics, and know the severity of the cases. Which we cannot do. That leaves 8 deaths (1 death due to bacterial pneumonia, and the rest for various pregnancy-related causes), for a rate of 0.3/1000, compared to the CNM statistics of 0.21/1000. However, four of these deaths were in the 42+ week group, which I previously noted statistically has a higher risk of death due to possible post-maturity and/or aging placenta. So, looking at just women in the “term” period, and excluding congenital/genetic birth defects, there were 4 deaths out of 23,130 births, for a rate of 0.17/1000, while the CNM stats remain at 0.21/1000.
All that said, there may be some deaths in the home-birth group that may have been prevented or delayed by immediate postpartum care. But this may also be analogous to the differences between birthing in a Level-III hospital versus your local county hospital. While most babies will be just fine without all the bells and whistles that a NICU or anything else such a hospital has to offer, some babies could have survived had there been the equipment, or pediatrician on staff, or perinatologist, or whatever might have made a difference in retrospect. Hindsight is 20/20. Some rural or small hospitals simply will not have everything on hand that the larger, state-of-the-art hospitals do have; but nobody suggests that it is “unsafe” for women to give birth in these hospitals, just on the off-chance that their baby is born with a birth defect which their local hospital cannot treat, and will have to transfer care to a larger hospital. While some defects can be known beforehand, not all can; and there are also false positives as well as false negatives.
None of this takes into account the number of babies who might die because they were born at the hospital, for instance, from an unnecessary C-section, which has an excess of neonatal deaths, compared to vaginal birth.