Causes of death in babies born at home

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.

11 Responses

  1. I’m not sure what you are arguing about. Johnson and Daviss have already acknowledged on their own website the truth of essentially every claim that I have made:

    They have acknowledged that they compared homebirth in 2000 with hospital birth in a bunch of out of date studies extending back to 1969.

    They have acknowledged that the correct comparison should have been to low risk hospital birth in 2000.

    They have acknowledged that the neonatal death rate of moderate risk hospital birth in 2000 was 0.9/1000 (including congenital anomalies).

    In other words, they have implicitly acknowledged that they deliberately misled people in the BMJ 2005 paper. That’s not in question any longer.

    Now they have attempted to salvage their paper by making different misleading claims:

    They claim that the hospital neonatal mortality rate for 2000 was unavailable when they submitted their paper in 2004, but that’s not true; the data was published in 2002.

    In the original paper, they claimed that the homebirth neonatal death rate was 2.6/1000 (including congenital anomalies), but now they’ve “re-evaluated” their OWN data and come up with a new number. Now they’re saying that their own data showed a neonatal death rate of 0.9/1000 but they didn’t realize it at the time they published their paper.

    They are making no effort to correct the BMJ paper by submitted a correction to the BMJ, which is the only appropriate response if they have changed their assessment of the data.

    Instead, they are planning to present the data at an APHA poster session in San Diego in a few weeks. As could have been predicted, this is a setting in which there is no peer review.

    The bottom line, Kathy, is that you and other homebirth advocates were scammed, and still don’t seem to realize it, even after the scam has been admitted.

  2. Amy, If you’re not sure what I’m arguing about, here’s an idea — maybe you shouldn’t comment! Perhaps you just need to reread the post until you do figure out what it’s about. You’re smart enough to pass med school, surely you can figure out my li’l ol’ posts.

    Kindly don’t confuse my blog with your “debate” blog (the very word implies a fair and honest discussion, and your site is not that). I’ve had so many of my comments deleted off of your supposed debate that I began making a copy of everything I wrote, because I was tired of working on a post, doing much research and word-crafting, posting it, having it say that the post was successful, and then having it disappear. The copy was so that I could quickly re-post what I had said, and usually (after about 3 times) it finally was allowed on. Not sure if you “slipped up and let it through” or someone responded to my post before you had a chance to delete it (I guess you have to sleep sometimes) or if you finally realized that I wasn’t giving up. Of course, that was back when I graced your blog with my presence, which I try not to make a habit of.

    I’m not sure why you’ve had to claim that they compared homebirth to older hospital-birth studies — they said that in the original paper. I’ve read the BMJ paper as well as their additional discussions on their paper, and they continually point out the difficulties of finding a suitable matched group from hospital stats as well as published studies, taking into account the varying risks of neonatal mortality based on factors like maternal age, parity, socioeconomic status, marital status, birthweight, etc. They do not say that the mortality rate was unavailable, but that the data that was available did not provide a like prospective group.

    Please cut and paste the precise sentence (in the paragraph, to provide context) of when Dr. Johnson & Ms. Davis ever “claimed that the homebirth neonatal mortality rate was 2.6/1000”, and provide the URL. I’ve just re-read the paper, and I see them consistently saying “intrapartum and neonatal mortality” and at least once “perinatal” (which is imprecise, since that typically includes all deaths from 22 or 28 weeks of pregnancy up through 7 days postpartum and would certainly include the antepartum deaths they mentioned in the original paper, but not several of the neonatal deaths, since they happened after 7 days).

    If I made any errors in my post, you may civilly point them out. If however, you want to bash Dr. Johnson & Ms. Daviss, you have your own blog for that. I have a delete button, and I give you fair warning in advance (unlike you) that I will not let this slide into the muck that characterizes your blog. I have engaged you many times on this subject in the past on your turf, to no avail. Neither of us has been able to get the other to see our side. Further discussion is useless unless one of us has new information. Which you don’t. Keep to the issues. Comment about what I have posted or nothing at all.

    Are breech and post-term births generally considered “low risk”? What is the intrapartum death rate of hospital births (statistics or studies, please — facts, not surmises)? Is it not true that neonatal mortality never includes any intrapartum deaths, since it is by definition, the death of newborns not pre-borns? Is it not fact that the neonatal mortality rate differs, based on race? and that taking births to white women excludes births to women of of other races? and that therefore one of the BMJ neonatal deaths must be excluded to better compare to lily-white births? Is it not true that babies born with anencephaly, Edward’s syndrome, Patau’s syndrome, and many other genetic conditions or congenital abnormalities almost always die in the neonatal period? Are you arguing with the facts I have presented about the CDC stats?

    You have repeatedly posted on numerous internet websites (blogs, e-articles, e-magazines, whatever) that the BMJ study shows a 2-3x greater risk of neonatal mortality. It does not. You have also posted that the 2003-2004 CDC stats show a 2-3x greater risk of neonatal mortality. This does not take into account unavoidable causes of death. If you were ignorant of this before, you cannot claim that now that I have pointed it out to you. I trust that from this point forward you will amend your comments on such websites to reflect this information, so that you will not be guilty of misleading people.

  3. I’ll let my comments speak for themselves. People are free to analyze the actual data. Ask anyone who knows any math or statistics, the BMJ 2005 study shows that homebirth has a neonatal death rate approximately triple the hospital neonatal death rate, and the Link Birth Infant Death 2003-2004 show that homebirth with a DEM is the most dangerous form of planned birth in the US. The only people who don’t appear to realize this are homebirth advocates.

  4. Amy, you continue to include intrapartum deaths as live births; and you pretend that the unavoidable deaths demonstrated in the CDC stats were somehow caused by these births happening at home with a non-CNM as the birth attendant. As supposed, you have nothing new to add to this discussion. As per usual, you refuse to respond to direction questions, and you continue to make misleading statements. A one-trick show.

    Oh, and since you had trouble figuring out what the original post is about, I’ll give you a hint — it’s a discussion of the causes of death of babies born at home (hence the title of the post). It’s one comprehensive post that looks at what lies beneath the bare numbers. With more candor than I’ve ever seen from you.

  5. Kathy, thank you for tackling this subject in a place where civil, intelligent discussion has a fighting chance. There are a couple of important points I’d like to bring up here – points that have been conveniently ignored and buried on the “debate” blog but are critical to a true understanding of what the numbers mean.

    First, when looking at death rates, you are correct in using a denominator that includes live births. However, in the BMJ article, the number “5418” represents the number of women choosing homebirth, not the number of live births. You would have to add in the number of twins that were born (I believe there were 13 sets?) and subtract the number of babies who died before birth. The denominator ends up being something like 5423 instead of 5418, which isn’t a huge difference, but is the only proper way to compare death rates. It adjusts the homebirth death rate slightly downward.

    Second, the final say in any comparison is statistical significance. Even if Dr. Amy’s claims were correct, the difference does not reach statistical significance. This means that any difference could be completely due to chance and cannot be ascribed to the different locations of birth. The difference could be 12 times as big and still not mean anything if it is not statistically significant. To ignore this is to participate in “USA Today statistics” which are used only to entertain or sensationalize a claim. Important decisions are being made on the basis of this information; it’s critical to fully understand all aspects of it. In epidemiology, lack of statistical significance is often the last word on the topic.

  6. I appreciate the analysis Kathy. You have broken it all down really nicely. Keep up the good work!

  7. Heidi, Thank you very much! I’ve just read a bit of your blog and am blown away! I’ll read more of it as soon as I get more time (hopefully tomorrow).

    Wendy, Thank you as well. I’m glad you pointed out the 13 sets of twins — I had totally forgotten about them. I also realized earlier today that I also made an error when taking out the one death in the non-white group — I didn’t subtract the mothers. According to documents available on the “Understanding Birth Better” website, there were 286 Hispanic or black women in the original group, and while I excluded the single death, I didn’t change the denominator to show just the non-Hispanic white group, nor the intrapartum deaths nor those due to lethal congenital anomalies.

    Also I’m glad you said that about statistical significance, because that is very important. I’ve read numerous studies and abstracts, and can’t even begin to recall how many concluded that although there was a numerical difference between the various groups, that it was not statistically significant. The first one that springs to mind is one I blogged about recently, on different fertility treatments. The study had three different groups, with live-birth rates ranging from 14% in the lowest group to 23% in the highest group. Yet the researchers concluded that the difference was not “significant.” To someone not familiar with this, or not told this, it would appear that since one group had nearly double the success rate of the least-successful group, that this was a significant difference.

  8. Just this past week, I met up with a doula… whose neighbour had a totally un-nescesarean. Her baby died the next week.
    How about my friend who lost her child, despite the crash section?
    Where is that data? Where are those studies?
    Cripes… head bashing to the table over and over again.
    Thank you for being a lone voice of reason in the wilderness.

  9. […] the BMJ, and the 2003-2004 CDC statistics. (I’ve written about these from a different angle here.) The BMJ study was prospective — that is, it took a group of then-pregnant women and […]

  10. […] hospital birth.” I’m planning another post in the near future on that, but here is one post in which I take on that statement, if you’re […]

  11. Gosh, Kathy, this makes so much clear.
    Thanks again.

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