Birth Book Giveaway at EnjoyBirth

Sheridan at EnjoyBirth is giving away a birth book at her blog. The book is called Labor of Love, and is written by a CNM about her journey into midwifery. It sounds like a great book to read — click here for more details about the book and the contest, including how you can enter to win the book as well!

B’s Birth Story

My middle sister has three children; this is the story of the birth of the middle one.

Her first birth was two years before, in a hospital with a CNM (she ended up with pitocin, but no epidural — just some injected narc like morphine or something). For some reason, that option was not available when B was born [either that CNM had moved, or the hospital had changed policies so she wasn’t allowed to practice, or something], so she opted for a home birth with a midwife. Our state does not require regulation for midwives, so I don’t know what this woman’s credentials or training were, although she had attended numerous women in our area who had chosen home birth (and eventually moved out of state, so not a possibility for me now).

My sister said that her “ideal” would be to have a midwife in the hospital — the midwife for the low-tech high-touch “natural” aspects that she wants, with the “safety net” of being the hospital should the need arise for quick action. That not being available, she opted to go with the midwife at home instead of an OB at the hospital.

My sister and her family had been living in their house for about two years at that point, and had not yet been able to afford to replace the carpet. The lady they bought the house from was elderly, senile, and let’s just say needed to wear diapers. While they had gotten the carpet thoroughly cleaned, it was the same carpet that was in the house when the previous owner was…using it. While this may seem like a completely off-the-wall paragraph for a birth story, it’s not; because my sister said that she had a real mental hangup about this carpet while she was in labor. Whenever the midwife knelt on the floor to check my sister, or anything else, my sister could only think about the fact that the midwife was probably kneeling where the senile old lady had peed. And she just felt like it was too dirty to give birth there.

Other “mental hangups” included that she was distracted by the messy closet. She told me afterwards that she kept staring at the closet door, hoping that somebody would take the hint to close it, but she never could quite get the words from her brain to her tongue, to actually tell someone to close the door. And finally, the previously mentioned feeling that the hospital was really safer, and she didn’t feel totally comfortable giving birth at home.

I don’t know when she went into labor, nor how long it was; the only thing I really remember that she said, was that she stayed at 6 cm dilation for 9 hours. As a second-time mother, that was quite a plateau! Her husband was a less than perfect labor partner, too. Let’s just say, he’s nearly the poster child for “men should go hunting while their wives give birth.” Rather than supporting and encouraging her through the difficult and painful contractions, he got irritated and tired of her “screaming” and was relieved when she finally went to the hospital so she could have an epidural. He’s a nice man and a good husband in many ways, but labor support is not one of them.

After having been stuck at 6 cm for so long (and being distracted by thoughts of urine-soaked carpet padding, a messy closet, and being not quite comfortable with the idea of giving birth at home), she finally went to the hospital. The midwife had thought about breaking her water in order to apply the head directly to the cervix, but the baby was still pretty high up, and not engaged, so she was worried that breaking the amniotic sac might precipitate a cord prolapse, so she was unwilling to take that step at home. [Note — a CNM friend said that she will “leak” the bag of waters, letting it out slowly, as an alternative to transferring to the hospital.]

So, off to the hospital they went. Perhaps it was the sitting in the car on the way to the hospital; perhaps it was that my sister was able to relax since she was away from the distractions at home; perhaps it was just a coincidence, but when they arrived at the hospital 20 minutes later, she was already dilated to 8 cm. They started her on pitocin and an epidural, and the baby was born soon after.

Lesson to learn: even when someone ought to be able to give birth at home, as far as level of risk and quality of care-provider, it doesn’t always mean that she will actually be able to. Distractions can interfere with labor in even the best of circumstances. I remember another story I read on an email list, in which a woman was just completely distracted by a drop of blood on her foot. She kept staring at it, waiting for somebody to wipe it off (I guess never thinking to do it herself, and certainly never speaking about it). La-la-labor land!

Ask Dr. Amy

Here are questions that have come to my mind that I would like Dr. Amy, or anyone else who knows the answer to them, to answer. Most of them I’ve previously asked, but I’ve either gotten no answer, or have not gotten a satisfactory answer. Some of them I may be asking for the first time.

1. Since a “debate” is supposedly honest and fair, isn’t it unfair to have you being the “moderator” of the Homebirth Debate blog/website? Isn’t that rather like Michael Savage or Michael Moore running a political debate? or like Adolph Hitler, Joseph Stalin or Mao Tse-tung running a religious debate?

2. Since a “debate” is supposedly honest and fair, isn’t it dishonest of you to delete comments with which you disagree?

3. Why do you delete so many comments? I’ve personally had so many of my comments deleted that I made a habit of saving my posts, so I could quickly re-post them. And I’ve heard from many others who likewise have had their comments deleted once posted. About how many comments per day do you delete, anyway? Why? — Is it because you can’t answer them?

4. Why do you require home-birth advocates to back up everything they say, when you and your minions rarely do? In fact, I’ve almost never seen you quote any study or link to any study which indicates what you say — you basically say, “Believe me, I’m a doctor,” whereas when we make similar claims, you say we have to cite sources before you believe us. Isn’t that an untenable double standard?

5. When home-birth advocates do back up what they say, with studies published in notable journals such as ACOG’s Green Journal, why do you then say that we don’t have the right to quote such studies, and demean our understanding of plain, written English?

6. Why do you take so many things out of context? For instance, back in December or early January, which was about the last time I took you up on your blog, I had just started this blog, and you checked it out, pulled a fragment of a sentence about breech birth out of what I had written, and mocked me on your blog, though what I had said was backed up by recent research: what you left out was “in the absence of these factors” but kept in “breech birth is safe.”

7. When I posted a few breech birth studies from the 80s on your blog, you said that was too old, and that many larger and more current studies showed the reverse. What are they? I’ve found many studies, from the year 2000 and onward, that demonstrate that automatic C-section is not evidenced-based. Where are the studies you mentioned?

8. Is the current 30% C-section rate outrageous or not? You said it was in a comment on another blog a couple of years ago — do you still hold to that opinion? Why or why not?

9. Should women be allowed to try to give birth vaginally after a previous Cesarean? Why or why not?

10. If yes, then why do you not start a blog on “VBAC debate”, like you have on homebirth? — afraid too many MDs and OBs will get on, and you can’t shut them up by saying, “I’ve got a medical degree and you don’t, so you have to believe everything I say”?

11. Is there anything that ACOG has said that you disagree with?

12. Are the following low-risk or high-risk: breech vaginal births, post-term births, and twins?

13. Why do you insist on saying that the mortality rate reported in the Johnson & Daviss study is neonatal, when it is a combined neonatal and intrapartum?

14. Are intrapartum deaths reported in government statistics? If so, where?

15. Are not intrapartum deaths a subset of stillbirths, in that the baby died during labor was born dead?

16. What is the intrapartum death rate for the year 2000? Or any year? I require facts, not surmises.

17. When a lethal fetal anomaly is discovered during pregnancy, what percentage of mothers have an abortion and/or preterm induction? (many people report a 95% termination rate for cases such as Down Syndrome and other fetal anomalies, which would significantly alter the rate of lethal anomalies in babies born at or after 37 weeks)

18. Is it not true that there are significant difficulties in reconciling prospective and retrospective studies, such as the BMJ study and the government vital statistics report?

19. Is it not true that one of the deaths in the J&D study was to a non-white woman, so it (and all other non-white births) must be excluded when attempting to compare it to neonatal death rate among white women in the National Vital Statistics Report?

20. Is the intrapartum mortality rate or the neonatal mortality rate presented in the prospective J&D study statistically significant, when compared to the retrospective NVSR? (please provide your reasoning and calculations)

21. Are the numbers from the CDC 2003-2004 statistically significant, or should other calculations be used to determine statistical significance?

22. In this post of mine, I showed that, according to the CDC 2003-2004 statistics, women who gave birth at home had 3.5 times the rate of babies with 4 lethal birth defects at 37+ weeks, compared to women who had a CNM in the hospital: 0.21/1000 vs. 0.06/1000. You said that could “easily be due to chance,” in a comment. Does that not mean that there are calculations and other things that must be done to determine if the overall death rate is also not “easily due to chance”?

23. Considering that the home-birth set had over 3x the number of babies with 4 selected lethal birth defects, why don’t you ever mention that when you launch into your diatribes against home-birth, but instead act as if it is statistically significant, never delving into the causes of death?

24. In the CDC stats, there are some 20 neonatal deaths attributed to factors with codes beginning with Q. Is it not a fact that sometimes babies die of these conditions even when born in the hospital? — that some of these conditions may be so severe that no amount of medical care can save severely affected babies?

25. Is it not necessary to know the severity of these cases, in order to determine whether these Q-coded deaths could have been prevented by immediate medical care, in order to say that the deaths of these babies was “preventable”?

26. There are several inaccuracies or at least questionable entries in the CDC stats — “other midwife” being the birth attendant at a hospital; CNMs performing C-sections, etc. — what happened? Several thousand typos? Shouldn’t the inaccuracies be questioned and verified before being quoted as being statistically significant? Isn’t it possible that some of the deaths were coded wrong? If so, that wouldn’t change the hospital statistics too much, since there are about 8 million births over the course of the two years; but there are only about 40,000 home-births in that same time, so one death in the home-birth group would make a bigger change than it would in the hospital-birth group.

27. While most births will occur before the end of 42 weeks, even without medical intervention, some women do not naturally go into labor at this time. Since the CDC stats group all births that occur from the start of week 42 until… whenever — it’s not listed — could be 50 weeks as far as we know — all in one category, isn’t it possible that there were some babies who had moved into the high-risk category for being post-dates, post-term, and/or post-mature, and probably should have “risked out” of home birth, yet were born at home? Wouldn’t that skew the results for babies born just in the term period?

28. In ACOG’s statement on the Supreme Court’s decision to uphold the Partial-Birth Abortion ban, Douglas W. Laube, MD, MEd, ACOG president, is quoted as saying: “It leaves no doubt that women’s health in America is perceived as being of little consequence…. We have seen a steady erosion of women’s reproductive rights in this country. The Supreme Court’s action today, though stunning, in many ways isn’t surprising given the current culture in which scientific knowledge frequently takes a back seat to subjective opinion.” Why is it that ACOG is so concerned about a woman’s right to legally end the life of the child she carries in her womb, but stands against her right to legally give birth to that child in the manner of her choosing?

29. ACOG has placed “‘Lay’ Midwives and Home Birth” in the second spot of its State Legislative Issues 2008 — why? You say it’s because of “safety” concerns. I think that’s a load of bull, and I’ll tell you why: the numbers just don’t add up. Even if your grossly inaccurate figures about the “excess rate of preventable mortality” were correct, which they’re not, at most, outlawing home birth completely would potentially save 80 babies’ lives per year. Maternal smoking and unmarried mothers are each associated with approximately 4/1000 greater neonatal mortality, and affect 400,000+ and 1.3 million+ babies, respectively, per year, or over 7500 dead babies that would have lived had their mothers not smoked or been married (I know these categories are not mutually exclusive, so there is undoubtedly some overlap).

30. I assume you’re a member of ACOG — could you tell them that on the page I just linked to, that they need a spell-check and/or an editor? I’d point out the error to you, but it’s pretty obvious.

31. You’ve complained about “defensive medicine” and the high C-section rate being due to OBs unwilling to take chances with letting labor continue normally; but the current laws make that reality. In a post you had a couple of months ago about C-section rates, in the ensuing discussion, the topic turned to this topic. Susanne complained that midwives just complained about the high C-section rate while making no efforts at altering legislation, and sneered at them for not helping. I don’t mean to sound sarcastic, but does ACOG really need the help of midwifery organizations such as NARM and MANA?

32. Has any midwifery organization tried to block legislation that is designed to make the malpractice system more fair or generous to doctors?

33. Doesn’t ACOG have something like 50,000 members who are all doctors and therefore probably earn at least six figures every year? Do they need the help of midwives, who are a fraction of the number, and make a fraction of the income, in order to pass this legislation?

34. If midwifery organizations hop on board with the medical liability reform, and throw their huge financial resources (one source said that a Wisconsin midwifery organization had a grand total of $3,000 for its lobbying budget, when the bill finally passed, but I guess every penny counts!) into the ring, would ACOG support home-birth midwives with their legislation, or at least not try to block it? After all, if midwifery organizations didn’t have to fight for survival, they would have more resources to help their brother obstetricians.

35. Why is it that promoting laws banning CPMs and home-birth is #2 on ACOG’s legislative agenda, when it affects so few people, while defensive medicine — particularly the outrageous C-section rate and the medically inappropriate forced repeat C-section instead of allowing VBACs — is way down at #5, under “medical liability reform”?

36. Previously, you’ve said that a 30% C-section rate is at least twice what it ought to be. How did you arrive at that conclusion? Do you still hold to that conclusion? Why or why not?

Excess Preventable Mortality?

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.

Prospective vs. Retrospective

Here is a webpage that discusses the two types of studies, along with their usual limitations, differences, and other important points. The main difference that is the starting point for this post is that a “prospective” study starts now and ends at some point in the future; while a “retrospective” study starts now and looks back to the past.

Why is that important? Many reasons, including that it is usually if not always difficult to reconcile the statistics produced by a study of one type with a study of another type.

Here is an example of what a retrospective study looks like — a person looks at babies who were born last year, and counts up mortality and morbidity, based on whether the baby was born by vaginal birth or C-section. A prospective study looks more like this — a person finds women who are currently pregnant, and follows them until they give birth, and sees how many of them had a C-section and how many gave birth vaginally, and what the mortality and morbidity of each group was.

In some ways, they may look similar, but the difference is important, when you compare and contrast the Johnson & Daviss Certified Professional Midwife study which was published in 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 followed them through the end of pregnancy and six weeks after birth. The CDC stats are retrospective — that is, it shows (among other things) where the baby was born, whether vaginally or by C-section, and who was the birth attendant; but it does not say anything about the plans or intentions of the mother.

Since the CDC stats are merely retrospective — showing what happened, not what was intended, there were doubtless many planned home births that ended up as hospital transfers. Most studies, as well as most midwives’ own records, indicate about a 10% hospital transfer rate; very few of those are emergencies, with most being due to women deciding they want or need medical pain relief, or there is a desire or need for labor induction or augmentation. So, we can figure that if the CDC statistics are correct (which I actually doubt, since there are some major discrepancies, including in-hospital births attended by “other midwife”, several “out of hospital” C-sections, and many thousand C-sections performed by CNMs), then they reflect only about 90% of planned home births. (Whether that has any bearing on mortality rates is debatable, especially since these statistics are just that — statistics — not a study which shows whether any apparent difference is actually statistically significant.) However, there were over 35,000 births attended by “other midwife” in 2003-2004, but if this is only 90% of the true number, then there would have been about 40,000 planned midwife-attended home births (and probably some of the out-of-hospital births not attended by midwives were planned home births, but the midwife couldn’t make it in time, either because of precipitous birth, or [like me] the mother just didn’t notify the midwife in time.) Had these women all participated in a prospective study, we would know for sure what their plans were, and what the outcome was. Since, however, it is retrospective, we don’t.

Another thing this data lacks is whether these “other midwives” were CPMs or not. This is one reason why the BMJ study looked only at CPMs, and not non-certified midwives —  CPMs had a standardized curriculum and training, whereas non-certified midwives maybe did, and maybe didn’t. Since my state is unregulated, I could be a midwife, although as close as I’ve come to midwifery school is reading Ina May’s Guide to Childbirth, and a few other pregnancy or birth books that are also included in some midwifery curricula. But I shouldn’t be lumped in together with well-educated and well-trained midwives. It’s simply not fair.

While the BMJ study was, indeed, prospective, tracking women who intended to give birth, listing the outcomes, if known (miscarriage, stillbirth, transferred for pregnancy complications, etc.), of the women who were initially registered, it is not a valid comparison just to say, “Hey, let’s look at these CDC stats over here, and find women of these characteristics, and say they match.” Only a similar prospective group, cared for by doctors, would be a valid match. Let me give you some examples to clarify this.

Let’s design on paper a study to compare outcomes of women who plan on giving birth at home with a CPM with those of women planning a hospital birth with an OB. First, we can’t just pick the same number of women, because there are some reasons that women would be excluded from home-birth from the start, which would not be a valid comparison to just randomly selecting the same number of women from an OB’s client roster. The women have to be matched in terms of health, because it’s not fair to have only healthy, low-risk women in the CPM group, and a mixed population in the OB group. They should also be matched as closely as possible in as many areas as possible, and here are the ones that first spring to my mind: age, race, parity (how many births they’ve already had), marital status, and smoking. Since there is a recognized difference in neonatal death rates for each of these, plus since smoking obviously increases the risk of complications including preterm birth and stillbirth, it wouldn’t be fair to have one study group be 95% married non-smokers while the other group was only 75%.

Just in case you didn’t read some of the additional discussion that the BMJ authors have available, the reason they did not get a prospective OB group like what I’m talking about here is that it was just too expensive for the grant they were given for the study.

Moving on… We now have our two matched groups — the CPM group of 5000 women matched to the OB group of 5000. (Many times when they match groups, they will have more in one group than the other; one group is probably self-limited in size, such as women who choose home birth, but the other has a much larger pool from which to choose, so having more women reduces the likelihood of differences being due to chance.) Starting in the first pregnancy, we track all outcomes, to see if there are any differences in mortality, morbidity, pregnancy outcome, etc., especially if these are statistically significant.

For instance, the rate of pre-eclampsia is anywhere from 2-5% of pregnancies. Many midwives suggest to their clients that they follow The Brewer Diet, as a means of reducing this risk. Were this study to find a significant difference in favor of midwifery care, that would be a tremendous boon to women and their babies. If, however, the difference were not significant, or if it were even in favor of obstetric care, then many midwives would have to rethink their current practice. Same for other health events, like gestational diabetes, because many women may start a pregnancy low-risk, and then be moved into a higher-risk category for previously unknown underlying health problems. One of my friends was like that — in her last pregnancy she ended up needing to be on heart medication, although she had never had any heart problems, nor any indication of problems, prior to her second pregnancy.

I’m not saying that there is some magic involved in midwifery care; I’m just saying it’s difficult to try to compare midwifery clients to obstetricians’ clients, unless it is done prospectively. Obviously, women who end up with a home birth attended by a midwife did not develop eclampsia, so merely looking at women retrospectively and noting a low or non-existent rate of PE among home-birthers means nothing. But, if, with the same or similar client profile, fewer midwifery clients have adverse health events (like developing preeclampsia or gestational diabetes), or there were fewer miscarriages or stillbirths, then the care that midwives give to their clients merits a closer look. Without such a study, we’ll never really know.

Going back to the problem of taking retrospective statistics and trying to apply them to a prospective study, I notice this potential discrepancy — and it is one in which the answer can only be speculated about — looking at, for example, the women in the BMJ study, we can see how many of them had miscarriages, stillbirths, intrapartum deaths, pregnancy complications necessitating referral to an OB, and neonatal deaths, because the researchers noted all of these things. Looking at government-collected statistics, however, we see only how many neonatal deaths there were, based on various criteria — race, maternal age, parity, gestational age at birth, etc. So, we can see, for example, how many babies died that were born to white women at 37 gestational weeks and up. What we cannot see is how many low-risk women (who would have qualified to have midwifery care and be in the prospective group) ended up giving birth pre-term. If women who have midwifery care have a lower rate of pre-term births than an equivalent group under obstetric care, then that is an important finding.

But we don’t know that, because these types of studies are expensive; and obstetricians’ clients contain women of all risk groups. To take a group of CNM-attended births (such as what you can do with the CDC stats), and say that it’s a like comparison is equally not valid; because although CNMs only attend low-risk births, the different state laws may require “risking out” women of varying criteria (which is another problem in CPM-attended births — different criteria, or in the case of non-certified midwives, perhaps even none at all). So you may still end up with a “mixed bag” — that of only ultra-low-risk births attended by CNMs with a possible mixture of low-risk, medium-risk, and even high-risk births (including twins, breeches, and women who absolutely refuse to go to the hospital) among CPMs and non-certified midwives.

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.

The AMA on Home Births

I read the story; and then when I searched for the actual document, the link took me to a file for downloading, instead of to a website. Here is the link, but if for some reason it doesn’t work, you can google “Resolution 205 on Home Deliveries” and get it — it’s the top link.

But here is the full text (except the footnotes):

AMERICAN MEDICAL ASSOCIATION HOUSE OF DELEGATES

Resolution: 205
(A-08)

Introduced by: American College of Obstetricians and Gynecologists

Subject: Home Deliveries

Referred to: Reference Committee B
(Craig W. Anderson, MD, Chair)

Whereas, Twenty-one states currently license midwives to attend home births, all using the certified professional midwife (CPM) credential (CPM or “lay” midwives), not the certified midwives (CM) credential which both the American College of Obstetricians and Gynecologists (ACOG) and American College of Nurse Midwives (ACNM) recognize#; and

Whereas, There has been much attention in the media by celebrities having home deliveries, with recent Today Show headings such as “Ricki Lake takes on baby birthing industry: Actress and former talk show host shares her at-home delivery in new film” #; and

Whereas, An apparently uncomplicated pregnancy or delivery can quickly become very complicated in the setting of maternal hemorrhage, shoulder dystocia, eclampsia or other obstetric emergencies, necessitating the need for rigorous standards, appropriate oversight of obstetric providers, and the availability of emergency care, for the health of both the mother and the baby during a delivery; therefore be it

RESOLVED, That our American Medical Association support the recent American College of Obstetricians and Gynecologists (ACOG) statement that “the safest setting for labor, delivery, and the immediate post-partum period is in the hospital, or a birthing center within a hospital complex, that meets standards jointly outlined by the American Academy of Pediatrics (AAP) and ACOG, or in a freestanding birthing center that meets the standards of the Accreditation Association for Ambulatory Health Care, The Joint Commission, or the American Association of Birth Centers” # (New HOD Policy); and be it further

RESOLVED, That our AMA develop model legislation in support of the concept that the safest setting for labor, delivery, and the immediate post-partum period is in the hospital, or a birthing center within a hospital complex, that meets standards jointly outlined by the AAP and ACOG, or in a freestanding birthing center that meets the standards of the Accreditation Association for Ambulatory Health Care, The Joint Commission, or the American Association of Birth Centers.” (Directive to Take Action)
Fiscal Note: Implement accordingly at estimated staff cost of $1,929.