One of the claims the anti-homebirth people (embodied in Dr. Amy Tuteur) make is that homebirth has a high rate of excess neonatal mortality which could have been prevented. Does it? From the CDC statistics, Dr. Amy has noted that the home births attended by “other midwife” have 1.15/1000 neonatal mortality, as opposed to hospital births attended by CNMs which have 0.37/1000. You can search my blog for other related posts, because I have written about this several times, but now I want to focus on one particular aspect — that of this apparent excess mortality being preventable.
For my purposes, I pull four causes of death from the CDC stats: anencephaly, thanatophoric short stature, Edwards’ Syndrome, and Patau’s Syndrome (in the “causes of death” codes, these are Q00.0, Q77.1, Q91.3, and Q91.7, if you wish to double-check me). Although there are many causes of death due to genetic or congenital reasons, these four all carry a near-100% neonatal mortality rate — that is, almost all of the babies born with these conditions die within the first 28 days, if they survive pregnancy and birth at all. (There may be other similar conditions, but these were the first that I found that all had this high neonatal mortality rate.) In fact, in quickly reading about these conditions, I discovered that in many cases, doctors refuse anything but palliative care (nutrition, hydration, etc.) for these infants, contending that any care such as surgeries is a waste of time, because they are believed to be hopeless and/or better off dead. Some even argue for euthanasia, just in case “natural processes” don’t kill these babies quickly enough.
So, being born in a hospital does not necessarily even lengthen the lives of these babies; and since stillbirths aren’t counted in these statistics, it’s anybody’s guess as to how many babies were conceived and were not aborted. (This website says that 95% of babies known [or suspected] to have anencephaly are aborted, while 55% of babies who are not aborted are stillborn. It also calls into question some of the accepted medical “facts” about anencephaly — that these babies can’t see or hear or feel — because of the life experiences of such parents. The longest-living baby with anencephaly in the U.S. is “Baby K” who survived two and a half years; and it’s possible that the true life expectancy of such babies is much longer than most doctors allow, if better medical care were given.) Most of these conditions can be suspected or known by prenatal genetic or ultrasound testing, and abortions are not counted in perinatal statistics, since they are intentional deaths, and perinatal mortality counts only unintentional deaths. What is not clear to me is if so-called “live birth abortions” or preterm inductions of labor are counted in these statistics if the baby survives the birth process and then is allowed to die without medical care; or if all of the preterm births in the statistics are from women who naturally went into labor prematurely.
Of the term group, the total neonatal mortality rate for just these four causes of death was 0.12/1000 in the CNM+MD+DO group, vs. 0.21/1000 in the “other midwife” group. Now, when I previously blogged about the high rate of definitely unavoidable or possibly unavoidable death in the “other midwife” group (including these deaths, as well as deaths due to conditions which may or may not be lethal depending on severity), Dr. Amy insisted that the inference she drew (that of DEM-attended home births having 2-3x the rate of neonatal mortality of CNM-attended hospital birth) were valid, and “the only people that don’t understand it” are home-birth advocates. I actually understand what she is saying very well, I just happen to disagree with her shallow assessment of the data.
Looking at just these four causes of death in the 37+ week group (for all women, not just non-hispanic white women giving birth to babies weighing 2500+ grams), the neonatal mortality rate in the CNM group is 0.06/1000, whereas in the “other midwife” group it is 0.21/1000. If there can be any sort of statistical inferences drawn from this, and since these deaths are unavoidable, it seems logical to assume that either more affected babies make it to term in the home-birth group (either because of a lower rate of abortion or preterm induction, or more women who choose hospital birth naturally go into premature labor), or more babies survive labor in the home-birth group. (It only makes sense that there would be a lower rate of abortion in women planning home-births, since many women cared for by midwives decline prenatal testing that can reveal an affected baby, so they would not have an abortion since they don’t realize their baby has a lethal defect, although even some nominally pro-life women will have an abortion or a “live-birth abortion” when faced with this news.) Dr. Amy either can’t or won’t understand these life-and-death issues, although they are plain to see. We know that a certain percentage of women will have an abortion when they find out their child has some birth defects, such as chromosomal abnormalities like Down’s, Patau’s, or Edwards’ Syndromes, or congenital birth defects like anencephaly. Many women will have an abortion if they merely suspect these conditions. But women who decline prenatal testing will not suspect that they are carrying such babies, and will not seek abortions.
So I say that the evidence strongly suggests that the 0.21/1000 neonatal mortality rate in the “other midwife” group for these 4 conditions, as compared to the much lower rates in the term period of the CNM group, or the combined hospital-birth group, reflects the true incidence of mortality from these conditions, because the hospital-birth group has numbers which are artificially lowered because of abortion, or perhaps a higher rate of stillbirth.
It’s also possible that women who find out that their babies have a lethal genetic or congenital condition seek out midwifery care, or that women who are more likely to have an affected child seek midwifery care. For instance, if women are uncomfortable with prenatal screening (such as the risk of miscarriage for amniocentesis), but their doctors try to force it on them anyway (which happened to a friend of mine who ultimately chose a home birth), they may “jump ship” and just totally avoid the medicalization of both pregnancy and birth. Even though this friend gave birth to a perfectly normal child, she was nearly 40 so was at a much higher risk of having a baby affected by a genetic condition. But she didn’t want to be pressured by the doctor to take a test that she just did not want to do — she wouldn’t have had an abortion (although she is “pro-choice”), and her two other children had special needs, so she knew what she was getting into. There is also the possibility that women who find out that their babies are negatively affected are pressured by their doctors to abort (I’ve heard of women being forced to undergo psychological counseling because they refused an abortion), and they similarly “jump ship” to midwifery care, rather than to stay with the doctor who wanted them to murder their unborn child. Who can blame them? Would you really want to continue your pregnancy and give birth under the “care” of the man or woman who wanted your child dead?
But, even if there are cases not as extreme as that, if you find out during pregnancy that your baby is certain not to live, and is expected to die before labor, or almost certainly during labor, might you not seek to give birth at home without all the hospital intrusions and protocols? — at home, where you can call the shots? where you don’t have to worry about seeing dozens of other women in labor or with their perfect newborns, when yours has a lethal condition? where you don’t have to leave the hospital with empty arms, while everyone else goes home with a living baby? where you can spend as much time with your dying or dead baby as you want to, without being rushed by busy nurses who need to process your baby and paperwork?
So I say again, as I’ve said before, we need to look at the facts behind the bare numbers. The neonatal statistics don’t take into account abortions for known or suspected fetal anomaly; and I think it’s pretty obvious that home-birthing women are less likely to have an abortion than the hospital population. Babies who are known to be affected are also more likely to be born by pre-term induction (“just getting over with the inevitable”), which would cause a marked difference if you look at just term births. If 95% of the known affected babies in the hospital group are either aborted or induced pre-term, then very few make it to term, as opposed to most of the affected babies in the home-birth group. (Probably a slight exaggeration… for the point of clarity.) But this would definitely alter the statistics — and we see a difference in statistics in term births.
But these deaths are unavoidable, and the question concerns preventable neonatal mortality. There are only two things that would prevent the neonatal deaths of these babies born with lethal birth defects — their death prior to birth, either by abortion or stillbirth, or intense medical care to prevent their natural deaths from the numerous things that may be wrong with these babies (many affected babies have multiple abnormalities). Not all babies with these conditions die in the first 28 days, even without heroic measures. Some babies live much longer than expected, lasting even a few months or rarely a few years, with just a little bit of medical help (such as extra oxygen, if their lungs or breathing is affected).
But it is disingenuous to say that home-birth has a higher rate of preventable mortality when a great percentage of that excess mortality is not preventable.
Filed under: studies & stuff Tagged: | abortion, anencephaly, cdc statistics, CNM, CPM, DEM, dr. amy, dr. amy tuteur, edwards' syndrome, home birth, hospital birth, midwife, midwifery, midwives, neonatal mortality, patau's syndrome, prenatal diagnosis, thanatophoric short stature