Midwives, home birth proven safe - contrary to ACOG's false assertion
by Amy Gates

Last week I wrote about The Big Push for Midwives, a national grassroots campaign pushing for the regulation and licensure of Certified Professional Midwives (CPMs) in all 50 states, Puerto Rico and the District of Columbia. As it currently stands, there are 26 states that ban CPMs. If caught practicing there, midwives could be subjected to fines, jail time, even face the possibility of a felony conviction in Missouri.

Despite the fact that other developed countries in the world that have adopted midwives as the primary care providers for healthy pregnant women, the United States has yet to catch on. One percent of American women choose to give birth at home. Just last week the American College of Obstetricians and Gynecologists (ACOG), a trade union representing the financial and professional interests of obstetricians, released a statement reiterating their opposition to home births and CPMs, and suggesting that mothers who give birth at home with a midwife are choosing the birth experience over the health of their baby. Rather than advocating for "quality health care for women" as the group claims is part of their work on their about page, the entire statement perpetuates FUD; Fear, Uncertainty, and Doubt.

The Big Push for Midwives campaign countered with their own press release stating the ACOG is Out of Touch with Needs of Childbearing Families and said not only do they claim "out-of-hospital birth is 'trendy,'" but they also try to play the “bad mother” card. The International Cesarean Awareness Network also issued a statement "condemning" the ACOG for their statements, as did the Childbirth Connection who states ACOG Place of Birth Policies Limit Women's Choices Without Justification and Contrary to the Evidence.

In addition to these organizations, many other sites and blogs have done an outstanding job of weighing in on this topic and have covered it in much more detail than I can attempt in this single post. Therefore I'm going to stick primarily with addressing the safety "concern."

The ACOG says, "It should be emphasized that studies comparing the safety and outcome of births in hospitals with those occurring in other settings in the US are limited and have not been scientifically rigorous." This, however, is a false assertion. According to Citizens for Midwifery, a number of rigorous scientific studies published in leading medical journals have found that for a healthy woman having a normal pregnancy, a planned, midwife-attended home birth is as safe as a hospital birth and with far lower rates of medical interventions. The most recent is also the largest study - with 5418 women participating - based on prospective reporting for all the births attended by Certified Professional Midwives in 2000, published in 2005 in the British Medical Journal. ("Outcomes of planned home births with certified professional midwives: large prospective study in North America." Kenneth C Johnson, senior epidemiologist, Betty-Anne Daviss, project manager. BMJ 2005;330:1416 (18 June).

The study also states:

What is already known on this topic

  • Planned home births for low risk women in high resource countries where midwifery is well integrated into the healthcare system are associated with similar safety to low risk hospital births
  • Midwives involved with home births are not well integrated into the healthcare system in the United States
  • Evidence on safety of such home births is limited

What this study adds

  • Planned home births with certified professional midwives in the United States had similar rates of intrapartum and neonatal mortality to those of low risk hospital births
  • Medical intervention rates for planned home births were lower than for planned low risk hospital births

If that study isn't convincing enough, then one need only look to other developed countries like Denmark, Sweden and the Netherlands, where midwifery is the primary model of care.

The organization of maternity services in Denmark, Sweden, and the Netherlands was studied under the sponsorship of the World Health Organization European Headquarters Office of Maternal and Child Health. Midwifery care is highly respected and is a central feature of obstetric care in each of these countries. In Denmark and Sweden, almost all births are in the hospital, and autonomous midwives are employed by national health services. About three-quarters of Dutch midwives are in independent practice, and 34% of Dutch women give birth at home. In each country midwives provide "the first line" of care for normal pregnant women and are viewed as essential to the excellent perinatal outcomes these three countries enjoy."- Models of midwifery care. Denmark, Sweden, and The Netherlands.

Also worth noting is Denmark's maternal mortality rate was 5 deaths per 100,000 live births according to the World Health Organization's Maternal Mortality in 2000 report. Compare that to the United States where the maternal death rate was 17 deaths per 100,000 live births.

The United Kingdom, another developed country, also supports home birth for women in uncomplicated pregnancies. The Royal College of Obstetricians and Gynecologists and the Royal College of Midwives Joint Statement No.2. from April 2007 states:

"The Royal College of Midwives (RCM) and the Royal College of Obstetricians and Gynaecologists (RCOG) support home birth for women with uncomplicated pregnancies. There is no reason why home birth should not be offered to women at low risk of complications and it may confer considerable benefits for them and their families. There is ample evidence showing that labouring at home increases a woman’s likelihood of a birth that is both satisfying and safe, with implications for her health and that of her baby."

Thanks to Rixa at The True Face of Birth for looking up and sharing that information.

The World Health Organization (WHO) itself recognizes the important role that midwives play in prenatal and birthing care. In the WHO's Department for Making Pregnancy Safer 2006 Annual Report, it is noted that there is a great need for midwives in both the industrialized and developing nations. "Evidence for the decisive role of skilled birth attendants (SBA), and particularly midwives, in reducing maternal mortality is plentiful from both the industrialized and developing countries."

I found it particularly interesting that the WHO is working to reduce maternal mortality in these developing nations and is looking to the training of more midwives to achieve this task, citing an example of how midwives have already helped in Malaysia and Sri Lanka. "In a study of how Malaysia and Sri Lanka successfully reduced their maternal mortality rates since the 1960s, it was noted that the outstanding feature of maternity-related health services in the two countries has been 'the pivotal role of trained and government-employed midwives. They have been relatively inexpensive, yet they have been the cornerstones for the expansion of an extensive health system to rural communities. They have provided accessible maternity services in hospitals and communities, gained respect from the communities they serve, and are described with affection and admiration by the managers and policy makers in each country.'”

In summary, we have a large North American study citing midwife/home birth safety; Denmark, the Netherlands, Sweden, and the United Kingdom looking to midwifery as the primary model of care; Denmark with a home birth rate of 34% and a lower maternal mortality rate than the United States; as well as the World Health Organization supporting midwifery in many developing nations around the world. All of these things seem to indicate that midwives and home birth are a very safe choice. So why is the ACOG so against it in the United States? Are American pregnant women any different from pregnant women elsewhere in the world?

The truth is that safety is not the ACOG's biggest motivating factor. It's money. Money makes the world go around. As Belly Tales points out, "ACOG is a professional organization supporting and marketing the services of its members: obstetricians. In other words, a lobby. ...the bottom line is always the bottom line."

If the ACOG would acknowledge that these studies and practices in other countries are very relevant and support the legalization and regulation of midwives, as well as call on physicians to work with them and provide back-up support rather than against them, it is then that they would truly make birth safer for all women.

The positive thing here is that people are taking notice and questioning the status quo. Celebrities are talking openly about their home birth experiences and mainstream magazines are covering it. Women and their partners are seeing The Business of Being Born and learning that there IS another way. Women are talking. They are asking questions. And the ACOG is getting nervous. Let's keep the buzz going.

"In every country where I have seen real progress in maternity care, it was women's groups working together with midwives that made the difference." - Marsden Wagner, MD, MSPH

If you'd like to write a letter to the ACOG, please direct it to:
American College of Obstetricians and Gynecologists
409 12th St., S.W., PO Box 96920
Washington, D.C. 20090-6920
202-638-5577
Or email: communications@acog.org

Finally, if you've had a home birth and feel strongly about this, I encourage you to spread the word and write about it on your own blog, then leave a link to your post here in the comments. Also, if you've blogged about your home birth experience, please leave a link to that post in the comments as well. Thank you.

Additional resources:
The Big Push for Midwives
Citizens for Midwifery
International Cesarean Awareness Network - ICAN’s Response to ACOG AND AABC Statements on VBAC and Homebirth
The Compleat Mother - Homebirth: As Safe As Birth Gets
The Birth Book Blog - Latest ACOG statement against home birth
Belly Tales - ACOG's statement on home births
Pushed Birth - Parsing the ACOG Statement Against “Cause Célèbre,” Home Birth
Refuse to be a womb pod - What do I think about ACOG's homebirth statement?
The True Face of Birth - 10 responses to ACOG's statement on home birth

Contributing editor Amy Gates also blogs about attachment parenting, activism, green living and photography at Crunchy Domestic Goddess.

Submitted by Amy Gates (view blog) on Tue, 02/12/2008 - 11:10am

Comments

 

midwife

We used a mid-wife who went with us to the hospital. It was the most amazing experience, yet not very respected in the rural South. I can not recommend mid-wifery enough. It was truely one the most amazing the experiences of my life (and I am not only referencing birth-- I mean the months spent with our midwife).

Submitted by bmama on Tue, 02/12/2008 - 21:54
 

bmama - thanks for sharing

bmama - thanks for sharing your experience. :) after having the midwifery model of care with my second pregnancy/birth, i couldn't imagine going back to the medical model of care.

Amy
Crunchy Domestic Goddess
BlogHers Act contributing editor

Submitted by Amy Gates on Wed, 02/13/2008 - 08:16
 

ACOG

Great post and I agree ACOG is getting "nervous" about the dissatisfaction women are having giving birth in hospitals.

I am not sure what they expected- they encouraged doctors not to perform breech births, forcing women to have C-sections- which in turn put their health and their baby's health in greater jeopardy than having a breech vaginal birth.

Breech delivery isn't even taught in medical schools anymore! The only group of providers who DO know how to deliver breech babies is midwives. Is it any wonder women who don't want an automatic C-section are rejecting OB's and hospitals and opting for homebirths?

What about the ban most hospitals have on VBAC's? Studies show that VBAC's are safer than repeat C-sections both in the short term and long term for the majority of women, and yet most hospitals won't allow them. If ACOG is so concerned with women’s health, why are these two procedures not offered as options?

This whole situation reminds me of what happened in the 70's- my mom and step mom who each had four children in the 1970's told me how awful it was to give birth in hospitals. They both told me stories about nurses immediately taking the baby away to the nursery after birth, and given bottles, even if the mother wanted to breastfeed. They would only bring the baby back every 4 hours.

Father's were not allowed to be present for the birth. My dad didn't even get to hold my brother until 2 days AFTER he was born. My dad said the first time he got to hold my brother was in the car, after my mom had been discharged from the hospital on the way home. He couldn't even hold his first-born in the hospital.

My step-mother told me how she kept "sneaking" out of her room to go to the nursery to get her baby. The nurses actually tried to restrain her! My step-mom had to fight with the nurses after giving birth so she could hold and breastfeed her baby. She finally told them she was going to sue them if she was not allowed to hold her baby. After that, they finally relented and "let" my stepmom take her baby back to her room to breastfeed.

After having her first two kids (my brother and I) in the hospital, my mother, as well as millions of other mothers, who had such bad experiences giving birth in hospitals decided "No more," and opted for home birth with midwives! There was an explosion of home birth in the 70's for the above reasons.

The hospitals reaction: they made birth more "baby and mom friendly”, finally allowing fathers to be present during the birth, allowing father’s to hold their baby in the hospital, allowing the baby to stay in the room with mom, and encouraging breastfeeding. This wasn't done out of the goodness of their hearts- they did it because they were losing millions and millions of dollars to homebirth. In the meantime, a lot of the organizations were working to discredit midwives and promote the idea that homebirth isn't safe. Sadly, that hasn't stopped and from ACOG's recent statement, it is only getting worse.

Now it has almost come full circle, 30+ years later, with women rejecting hospital births. Women are staring to say "No more," and opting for homebirths, so they can have the birth that they desire for themselves and their babies.

I predict as this trend keeps growing, we will see a shift in the hospitals, policies, allowing more breech deliveries and VBAC's-only because they will be forced to, if they want to survive- just like they changed their policies in the 70's.

ACOG's ridiculous claim that homebirth is more dangerous can only go so far, and I believe a lot of women already know better than that. Hospitals will eventually realize their bottom lines are suffering and be forced to offer women the types of births they desire.

ACOG is shooting themselves in the foot with this statement. They have reversed themselves before, and they would be crazy not to immediately retract this statement, and apologize to every woman for issuing such a foolish statement, insulting the intelligence of every woman in this country.

With “scare tactics” like this, and the unnecessary birth restrictions they encourage, no wonder women want home births. ACOG is reaping what they have sowed.

Submitted by amamasblog on Tue, 02/12/2008 - 22:46
 

amamasblog - thank you for

amamasblog -

thank you for sharing the experiences of your mother and step-mom.

the more things change, the more they stay the same, huh? it certainly becomes hard to trust an institution that has such a bad track record when it comes to care and respect for the mother and baby.

you are right in that women are much smarter than the ACOG gives them credit for. the scare tactics will only work for so long.

Amy
Crunchy Domestic Goddess
BlogHers Act contributing editor

Submitted by Amy Gates on Wed, 02/13/2008 - 08:21
 

Homebirth has an increased rate of neonatal
death

There are so many factual errors in this piece that it is difficult to know where to begin, but I will try to address the most egregious ones.

"According to Citizens for Midwifery, a number of rigorous scientific studies published in leading medical journals have found that for a healthy woman having a normal pregnancy, a planned, midwife-attended home birth is as safe as a hospital birth and with far lower rates of medical interventions."

That statement is false. To date there are NO studies that show that homebirth is as safe as hospital birth. Sure there are studies that CLAIM to show that homebirth is as safe as hospital birth, but they do that by comparing homebirth with low risk women to hospital birth with high risk women or with hospital birth many years before the homebirths.

"The most recent is also the largest study - with 5418 women participating - based on prospective reporting for all the births attended by Certified Professional Midwives in 2000, published in 2005 in the British Medical Journal. ("Outcomes of planned home births with certified professional midwives: large prospective study in North America." Kenneth C Johnson, senior epidemiologist, Betty-Anne Daviss, project manager. BMJ 2005;330:1416 (18 June)."

That study ACTUALLY shows that homebirth with a midwife in 2000 had a neonatal death rate almost 3 times HIGHER than hospital birth for low risk women in 2000. The authors simply "neglected" to mention the neonatal death rate for hospital birth in 2000. Instead they compared homebirth in 2000 to out of date papers about home and hospital birth extending back as far back as 1969.

"If that study isn't convincing enough, then one need only look to other developed countries like Denmark, Sweden and the Netherlands, where midwifery is the primary model of care"

Of course, Denmark, the UK and the Netherland, all countries that you praise for higher rates of homebirth, also have higher rates of perinatal mortality (the best statistical indicator of obstetric care). That's what the World Health Organization 2006 report on perinatal mortality shows.

"In summary, we have a large North American study citing midwife/home birth safety; Denmark, the Netherlands, Sweden, and the United Kingdom looking to midwifery as the primary model of care; Denmark with a home birth rate of 34% and a lower maternal mortality rate than the United States; as well as the World Health Organization supporting midwifery in many developing nations around the world. All of these things seem to indicate that midwives and home birth are a very safe choice."

Wrong, the BMJ study does NOT show homebirth to be as safe as hospital birth. Wrong, Denmark, the UK, and the Netherlands have higher rates of perinatal mortality that the US. Wrong, the World Health Organization supports midwifery in developing nations as opposed to untrained traditional birth attendants; there are no obstetricians available.

amygeekgrl, you've been scammed. Homebirth advocacy is based on mistruths, half truths and outright deceptions, and you've simply repeated many of them. Please consider doing some independent research on the subject, rather than accepting the word of professional midwifery advocacy groups.

Amy TuteurMD

Submitted by Amy TuteurMD on Wed, 02/13/2008 - 04:33
 

Homebirth Debate

I'm a fan of "independent research" and am confident that Amy has done a good bit of that. In an effort to assist others in doing their own research:

Dr Amy Teuter of Ask Dr Amy (a premium service that allows you to pay $4.95 for Dr Amy to tell you what your chance of pregnancy is.)

Dr Amy Teuter of Homebirth Debate blog

Here's a quote from Amy's recent blog post on her Homebirth Debate blog:

The Big Push for Midwives is actually a nationally coordinated campaign to promote the licensing of a second, inferior class of midwife with inadequate education and indadequate training, because those women won't make money otherwise.

Check out Amy's post and do not skip the 166 comments in about 24 hours...

Fascinating reading all around.

~Denise
BlogHer Community Manager

Flamingo House Happenings

Submitted by Denise on Wed, 02/13/2008 - 08:50
 

Terrifying

It is terrifying what is going on in the birthing world. I gave birth with my midwife, in a hospital. I liked the fact that I was in a hospital, because if something did go wrong, there was immediate intervention available... HOWEVER.. my first birth experience was so wonderful, so amazing, because I was in charge of my experience, that I'm terrified for the second. I don't want a doctor to mandate what is going on with my body and my baby, when there is nothing *wrong* with me. I want my midwives back. The ones who didn't push epidurals and bag IVs, needles and C-Sections (yet didn't judge me when I needed something to help for the pain)... The ones that let me run the show. I think if more women had birth experiences through midwives, there would be far fewer C-Sections, far more breastfeeders, and far fewer complications.

Submitted by MommaMary on Wed, 02/13/2008 - 08:53
 

MommaMary - Do you not have

MommaMary -

Do you not have the option of seeing a midwife the second time around? Would you consider a home birth? I had a hospital birth with my first child and a home birth with my second. I didn't decide on a home birth until half-way through my pregnancy, but after finding a midwife I felt 100% comfortable with, it definitely seemed like the right thing for me and my family. I had a great experience - even with a surprise breech birth.

"I think if more women had birth experiences through midwives, there would be far fewer C-Sections, far more breastfeeders, and far fewer complications."

AMEN!

Amy
Crunchy Domestic Goddess
BlogHers Act contributing editor

Submitted by Amy Gates on Wed, 02/13/2008 - 20:14
 

Quite the Drive...

Amy --

My husband is in the Military, and we've moved to a rather conservative area of California. I am currently not, although trying to become pregant, so I've been asking around about who people have seen as far as OB's go. From everything I've heard, in order to see a midwife, I have to drive about 50 miles. I'm not comfortable going that far to see anyone.

I have not yet found a midwife in my area. I am not done looking, though, and I honestly haven't looked very hard. But, when I find her, I'll be happy... Then the only battle will be getting them to take my health insurance.

As for the home birth, I don't know that my husband would be comfortable with that, and that is something that has to be a joint decision. I'm fine having a baby in a hospital, but I'd much rather have a midwife than a doctor. My first experience was extremely wonderful. Mostly because of my midwife, and partly because the hospital had wonderful rooms for labor and delivery. Giant tubs, giving you the option of water birth. I was allowed to sit and soak during labor, Dimmable lights, with stereos built in.. Quite a homey atmosphere... I would say it was more like a birthing center inside a hospital. I will consider home birth vs. birth in the hospital much like I did my pain management for the first baby.. I'll educate myself about the options, and then decide when I get there. ;)

Oh, and in Lincoln, Nebraska.. MY Midwives worked with the nurses, doctors and hospital amazingly. Without that partnership, I wouldn't have had the wonderful experience I did. My midwife worked out of an OB's office, who would have preformed a C-Section had something gone terribly wrong, My nurses at the hospital worked wonderfully with my midwife... and even commented how much better, calmer and more natural the birth experience was when she was in charge, rather than a doctor... Maybe they've got it right there and other areas need to take note?

Submitted by MommaMary on Thu, 02/14/2008 - 08:48
 

Mary - If home birth

Mary -

If home birth interests you even a little bit, when the time comes, I'd highly suggest talking to a few midwives and including your husband so you both can ask any and all questions you might have. You might find that after doing that, you (and he) feel a lot more comfortable with the idea. Then again, you might decide it's not right for you. But I'd hate for you to exclude it without fully exploring it, especially if you options for hospitals whereever you are living at the time are less than stellar. My husband definitely had his concerns when I started thinking about a home birth, but after we met with the one we choose and got all of our questions answered, we both felt comfortable that it was the right choice for us. :)

We had to pay out of pocket for our midwife and are still working on getting the insurance company to reimburse us. Even if we don't get the money back though, I feel it was very well spent and I would do it again.

That's awesome that everyone worked together so well in Lincoln, Neb. If only it could be that way everywhere. Someday, right? :)

Amy
Crunchy Domestic Goddess
BlogHers Act contributing editor

Submitted by Amy Gates on Fri, 02/15/2008 - 15:03
 

thank you!

Thank you especially for the links to the WHO annual report and the BabyWorld celeb news. I hadn't seen those before. Childbirth Connection is one of my favorite resources for evidence-based birth information. And I'm quite proud that ICAN responded to these press releases in a timely manner though I take issue with the word "condemn".

You are right, birth activists are really speaking out about ACOG's and the AABC's resistance to choices in childbirth. If I were to "plug" any one of my recent posts, it would be http://labortrials.wordpress.com/2008/02/12/thought-provoking/ because of a comment I excerpted from another site.

Best wishes,
Kimberly
http://labortrials.wordpress.com

Submitted by labortrials on Wed, 02/13/2008 - 10:43
 

excellent quote you shared

kimberly (labortrials) - thank you for sharing that post with me. such an excellent point in that quote you shared. i hope you don't mind if i share it here as well.

"I’ve heard the argument that it’s inconvenient for hospitals to have to rally around and scramble when a homebirth mother takes that risk and it fails. While I see what these people are saying, I must also point out that we also rally around for every other emergency in life. We don’t judge the drug addicts who come in overdosed - we treat them. We don’t judge the obese who come in with MI’s. - we treat them. We don’t judge the diabetic who refuses to take his meds yet wants medical help when he has a diabetic crisis - we treat him. We don’t judge the elderly for forgetting their CHF meds and overloading - we treat them. We don’t judge many other behaviors which really ARE obviously poor choices - because they are just that - choices. Mothers deserve the same treatment." -- Comment from Team Harris

Amy
Crunchy Domestic Goddess
BlogHers Act contributing editor

Submitted by Amy Gates on Wed, 02/13/2008 - 20:25
 

Great post

Thanks for writing this. It's great. Here's my attempt to blog about it.

http://intedomine.blogspot.com/2008/02/earthy-birthy-mama-says-mouthful....

I think everyone should check out ICAN's reponse. I think it was thoughtful.http://www.ican-online.org/advocacy/ican-responds

Submitted by aedyrn on Wed, 02/13/2008 - 19:48
 

and thanks for your blog too

aedyrn -
thank you for sharing your post.
you said: "Wouldn't it be great if OBs, CNMs and CPMs could all actually work together in a supportive fashion to give the best maternity care to women in this country?"
yes!! perhaps we can achieve this by the time our children are having babies of their own or even sooner. :)

Amy
Crunchy Domestic Goddess
BlogHers Act contributing editor

Submitted by Amy Gates on Wed, 02/13/2008 - 20:43
 

Dr. Amy's comment

Also, real quick about dr. Amy's comment. I don't think anyone is trying to claim that home birth is safer for high risk women then hospital birth. I think most of the studies explicitly state that we are talking about home birth for low risk women. Homebirth midwives are not going to work with high risk women.

So, just as you can not say home birth is ALWAYS the safest option you also can not simply state that home birth is NEVER a safe option.

Home birth has been shown to be safe for low risk women.

Submitted by aedyrn on Wed, 02/13/2008 - 20:03
 

Increased rate of neonatal death for LOW risk
women, too.

aedyrn:

"Home birth has been shown to be safe for low risk women"

No, homebirth has NOT been shows to be safe for low risk women. That's my point. The scientific evidence shows that homebirth has an increased risk of neonatal death ABOVE the neonatal death rate for LOW risk women in the hospital.

Women cannot make an informed decision about homebirth if homebirth advocates withhold the safety information or are dishonest about it. I know that homebirth publications assert that the scientific evidence shows homebirth to be as safe as hospital birth. That claim is false.

Women also need to know that MANA (the Midwives Alliance of North America), the trade union for certified professional midwives (CPMs), has been collecting data on homebirth since 2000. The data from 2000 was used by Johnson and Daviss in the BMJ 2005 study; Johnson is the former Director of Research for MANA. MANA has assembled what may be the largest collection of data on homebirth, perhaps as many as 30,000 homebirths.

There's a big problem, though. MANA is withholding the data. MANA has publicly announced that the data is available, but ONLY to midwifery organizations that can prove they will use the data for the "advancement of midwifery". Even then, midwifery organizations are required to sign a legal non-disclosure agreement promising not to reveal any of the data to anyone else. It does not take a rocket scientist to suspect that MANA's database almost certainly shows definitively that homebirth with a CPM to have a higher neonatal death rate.

We can get some idea of what is the database by looking at state statistics from those states that have a category for planned homebirths with a direct entry midwife in the state's vital statistics. For example, Wisconsin state statistics show that in every year from 2000-2006, PLANNED homebirth with a direct entry midwife had a neonatal mortality rate 2-5 higher than planned hospital birth with a nurse midwife.

If homebirth advocates are concerned about the truth, they should take a close look at available statistics, and they should pressure MANA to release the national safety statistics.

Amy TuteurMD

Submitted by Amy TuteurMD on Thu, 02/14/2008 - 03:58
 

Homebirth statistics

Women also need to know that MANA (the Midwives Alliance of North America), the trade union for certified professional midwives (CPMs), has been collecting data on homebirth since 2000. The data from 2000 was used by Johnson and Daviss in the BMJ 2005 study; Johnson is the former Director of Research for MANA. MANA has assembled what may be the largest collection of data on homebirth, perhaps as many as 30,000 homebirths.

There's a big problem, though. MANA is withholding the data. MANA has publicly announced that the data is available, but ONLY to midwifery organizations that can prove they will use the data for the "advancement of midwifery". Even then, midwifery organizations are required to sign a legal non-disclosure agreement promising not to reveal any of the data to anyone else. It does not take a rocket scientist to suspect that MANA's database almost certainly shows definitively that homebirth with a CPM to have a higher neonatal death rate.

We can get some idea of what is the database by looking at state statistics from those states that have a category for planned homebirths with a direct entry midwife in the state's vital statistics. For example, Wisconsin state statistics show that in every year from 2000-2006, PLANNED homebirth with a direct entry midwife had a neonatal mortality rate 2-5 higher than planned hospital birth with a nurse midwife.

If homebirth advocates are concerned about the truth, they should take a close look at available statistics, and they should pressure MANA to release the national safety statistics.

IF what you claim is true, then I agree with you. What independent statistics do your recommend? NIH? Otherwise how do you suggest we gather these types of statistics? I will forward your post to a MANA midwife and ask her about this as well.

~ Kimberly
http://labortrials.wordpress.com

Submitted by labortrials on Thu, 02/14/2008 - 11:28
 

Sources for statistics

Kimberly:

"IF what you claim is true, then I agree with you. What independent statistics do your recommend? "

The National Center for Health Statistics publishes extensive data on births, deaths, and linked birth-infant deaths (including the statistics that Johnson and Daviss used in their study, though they "neglected" to mention the neonatal death rate in the hospital). Each state publishes its own statistics as well.

Amy TuteurMD

Submitted by Amy TuteurMD on Thu, 02/14/2008 - 14:02
 

the neonatal mortality study

Those of you who'd like to do your own research on the neonatal death rate might find this response interesting (from Henci Goer)

Amy
Crunchy Domestic Goddess
BlogHers Act contributing editor

Submitted by Amy Gates on Thu, 02/14/2008 - 08:47
 

Johnson and Daviss have acknowledged my
calculations are correct

"Those of you who'd like to do your own research on the neonatal death rate might find this response interesting (from Henci Goer)"

They might find it even more interesting to know that despite Henci Goer's efforts to deny it, Johnson and Daviss have acknowledged that my calculations are correct.

According to their website Understanding Birth Better:

"... Since our article was submitted for publication in 2004, the NIH has published analysis more closely comparable than was available at that time, and some have tried to use it as a comparison. While we still do not offer the comparison as a completely direct one, as it is the closest we have and the comparison is occurring regardless of our cautions, we offer the following adjustments that have to be made to provide the comparison of the CPM2000 analysis in as accurate a manner as is possible with the published NIH analysis."

So Johnson and Daviss acknowledge that the NIH data is "the closest that we have" but they offer a disingenuous excuse for their failure to to mention it in their study. They claim: "Since our article was submitted for publication in 2004, the NIH has published analysis more closely comparable than was available at that time". However, the relevant data was published in 2002, long before their paper was submitted (Infant Mortality Statistics from the 2000 Period Linked Birth/Infant Death Data Set, published August 29, 2002). Moreover, even before publication of the analysis, Johnson and Daviss had the raw data in their possession. They used that raw data from 2000 to calculate the rates of hospital interventions, so they were fully aware of the mortality data at all times.

Johnson and Daviss also publically acknowledge that my specific calculation of the hospital neonatal death rate in 2000 is correct:

"Thus a crude comparison of the comparable rates for non-Hispanic white >37 week babies in hospital in the year 2000 would be about 0.91 neonatal deaths/1000 live births ..."

That is almost exactly the figure I reached in my analysis of the hospital data in my post to Henci Goer. Goer's refusal to acknowledge the validity of my calculations reflects either an inability to understand the issue, or the willful desire to dismiss and discredit what she knew to be true. Either way, it does not reflect favorably on the reliability of her analysis.

The Johnson and Daviss 2005 BMJ study always showed and continues to show that homebirth has a higher neonatal death rate than hospital birth. Indeed, the rate is almost 3 times higher. Johnson and Daviss deliberately and disingenuously tried to obscure that fact in the original article. They now acknowledge that they used an inappropriate comparison group, yet their explanation is difficult to accept. They claim that the appropriate data was not available, even though it had been published 2 years before.

Amy TuteurMD

Submitted by Amy TuteurMD on Thu, 02/14/2008 - 09:22
 

I disagree

As a consumer in search of the truth, I like to do my own research, not just accept what is handed to me regardless of who it is coming from.

According to Johnson and Daviss's summary copied and pasted below, which can also be read here, home birth was found to be AS SAFE AS hospital birth.

I encourage you all to read the summary and/or any of the additional information on that page, and then make up your own minds.

(bolding below for emphasis is mine)

Summary

We compare the CPM2000 neonatal mortality rate among planned homebirths to the U.S. National Institutes of Health (NIH) neonatal mortality rate for births in hospital to U.S. non-Hispanic white women of 37 weeks plus gestation in the year 2004. Adjustments are made to ensure that the comparison is as close as possible to comparing like with like. This includes removal from the CPM2000 death rate of intrapartum mortality, 3 deaths involving lethal birth defects unlikely to have been carried to term in the hospital population, and 1 death and 286 births among African-American and Hispanic women. After making the necessary adjustments that were possible, the neonatal death rate in both datasets was just under 1 death per 1000. Our conclusions remains unchanged from those in the original article -- the neonatal mortality rate for low risk women in North America using certified professional midwives is similar to that for low risk women in hospital in the U.S., and the intervention rates are much lower. We note that the premature birth rate for the NIH non-Hispanic white births in hospital was 11.3%, more than double the rate for the women cared for by Certified Professional Midwives (CPMs). Higher prematurity is a serious concern for the U.S. hospital births, because prematurity is associated with much higher perinatal mortality and morbidity.

Amy
Crunchy Domestic Goddess
BlogHers Act contributing editor

Submitted by Amy Gates on Sun, 02/17/2008 - 20:14
 

You just accepted J&D's ridiculous
explanation without question

amygeekgrl:

"As a consumer in search of the truth, I like to do my own research, not just accept what is handed to me regardless of who it is coming from."

Really? You just swallowed Johnson and Daviss' desperate attempt to salvage their study.

As they say in politics, it's not the crime, but the cover up. Johnson and Daviss are now acknowledging that they used inappropriate data for comparison with homebirth, but claiming that the correct data was not available at that time. The relevant data was in their possession the entire time, and it was even released publically years before they made their erroneous comparisons. It is is difficult to imagine a legitimate reason why a professional statistician would deliberately use the wrong statistics for comparison when the right statistics were available and actually in his possession. It seems to me that the only possible explanation is that they knew all along that their study showed that homebirth has an increased risk of preventable neonatal death compared to hospital birth.

Having acknowledged the real neonatal death rate in the hospital in 2000 of 0.9/1000, they face a serious problem; their study reported a neonatal death rate at homebirth of 2.6/1000 (uncorrected for congenital anomalies). Once again, they resort to disingenuous and deliberately misleading claims.

Let's look at their efforts to extricate themselves from the inevitable conclusion that homebirth is not as safe as hospital birth and why those attempts are misleading and invalid. Johnson and Daviss claim:
"A crude comparison of the CPM2000 death rate to the neonatal mortality rate among U.S. Non-Hispanic White women with 37 week plus births would also require the following exclusions:

5 intrapartum deaths need to be removed as the NIH data report only on live births and thus include only neonatal deaths"

According to Johnson and Daviss (farther down the page): Intrapartum Mortality - baby who died during labour (before birth). So a true intrapartum death is one in which the baby is born without any sign of life at all, not even one pulsation of the umbilical cord. Yet if you look at the descriptions of the "intrapartum deaths" in the BMJ study, it is clear that some, if not all of them are misclassified. For example, one baby is even listed as having an initial Apgar score of 1. It is very important to understand that a baby who cannot be resuscitated is NOT an intrapartum death. Unless Johnson and Daviss can show that these babies were born and had absolutely no sign of life, and therefore never received birth certificates, we must assume that these are neonatal deaths.

Johnson and Daviss also try to exclude congenital anomalies from the homebirth group, even though they are included in the hospital birth group:

"3 neonatal deaths caused by fatal birth defects need to be removed. All three of these deaths would have occurred regardless of whether the birth was planned at initiation of labour to be in hospital or at home."

If congenital anomalies are in the hospital group, they MUST be included in the homebirth group, no matter how much or why Johnson and Daviss wish to exclude them. However, their excuse for excluding them is particularly unpersuasive and disingenuous: "Had these three birth defect deaths occurred among the hospital population in the present medical culture, they would have been far more likely than not to have been induced or terminated before term." This is an absurd claim: fully 25% of the neonatal deaths in the hospital group were due to congenital anomalies. There was actually a lower rate of congenital anomalies in the homebirth group than in the hospital group, not an artificially higher rate.

Finally, they also want to exclude "1 home birth neonatal death that was among the 286 Hispanic and African-American births in the dataset. Both the death and 286 births need to be removed from the comparison as they did not fit the non-Hispanic white women category provided by the NIH." That's perfectly legitimate, but that doesn't mean that we don't need to take that death into account. It simply means that we must compare the death rate among Hispanics and African-Americans at homebirth to the same groups giving birth in the hospital.

The bottom line is that the 5 "intrapartum" deaths and the 3 congenital anomalies CANNOT be removed from the homebirth deaths. The comparable death rate is not 5 among 5,132 but 13 among 5,132 for a homebirth death rate of 2.5/1000. The homebirth death rate is almost triple that of the hospital death rate for low risk white women at term.

The Johnson and Daviss 2005 BMJ study always showed and continues to show that homebirth has a higher neonatal death rate than hospital birth. Indeed, the rate is almost 3 times higher. Johnson and Daviss deliberately and disingenuously tried to obscure that fact in the original article. They now acknowledge that they used an inappropriate comparison group, yet their explanation is completely unbelievable. They claim that the appropriate data was not available, even though it had been published 2 years before. In addition, they are now making new invalid and misleading claims in attempt to avoid the inevitable and obvious conclusion that their study showed that homebirth has an increased risk of neonatal death.

Amy TuteurMD

Submitted by Amy TuteurMD on Mon, 02/18/2008 - 07:10
 

The Johnson and Daviss Q&A

Further reading: BMJ Home Birth Study Questions

Amy
Crunchy Domestic Goddess
BlogHers Act contributing editor

Submitted by Amy Gates on Thu, 02/14/2008 - 11:59
 

ah HA!

Brilliant. Thank you, Amy you crunchy goddess you!

~ Kimberly
http://labortrials.wordpress.com

Submitted by labortrials on Thu, 02/14/2008 - 12:59
 

More to be concerned about...

I know the argument here is about Home vs. Hospital Birth... But I think it is also about Dr. Vs. Midwife treatment. I believe the midwife treatment of pregnancy is an enormously different approach to birth than a traditional doctor. Why?

Midwives do more that 'treat' pregnancy. They educate their patients. Each appointment is a time to learn about what is going to happen for the next few weeks. No need to spend hours online, or reading about pregnancy, worrying about every little thing. Sure, some doctors may do this, and their nurses have a big part in it too, but face it. Doctors don't have (or often take) the time to do all of that. I didn't see a whole practice of doctors and nurses who never took the time to get to know me personally, I saw ONE midwife, and her partner when necessary. For the first half of my pregnancy I went to a traditional OB/GYN clinic, with a traditional Doctor.. or rather, doctors. I never saw the same nurse, OR the same doctor. I saw a different person every time. There was no consistency in care.

My midwife KNEW me.. knew my moods, the way I behaved, and when it came time to give birth, she knew what to do to help me. Midwives take care of everything... from the intial weigh-in to the actual birth process. They take their time to answer questions and make sure that the patient is informed about their options and choices regarding pain management. A midwife comes when you go INTO labor. They are there to help with paint management, and to help you through the LABOR and delivery. Often, Doctors show up when you are 10cm dilated, deliver the baby and leave.

I think this whole issue is being fought because DOCTORS are afraid they are going to lose their patients to MIDWIVES (and more importantly... lose money)... And, if more women were to give birth using them and then talk about their experiences, they would be right. They would be losing patients. Because, in my experience, midwives treat the whole person AS A PERSON going through a NATURAL FUNCTION of the human body, rather than a disease that needs to be treated. Midwives don't JUMP to 'fix' things that aren't broken (ie, give C-Sections) to avoid lawsuits, and they definitely don't 'demand' that their patients do anything that is not necessary.

Unecessary things Doctors do that midwives won't: (for a normal low risk pregnancy)

* Midwives will NOT require you to have an IV, just because you are pregnant.
* Midwives will NOT require the use of a Catheter.. You can pee on your own.
* Midwives do NOT perform uneccessary and sometimes dangerous cervix checks. Checking for dilation can introduce bacteria and cause false contractions, not to mention get a pregnant woman's hopes up, or down because of her progress or lack thereof. Not to mention, that having your progress checked when you're only 1CM dilated... It's not exactly the most comfortable thing in the world. That to me, was more traumatic than the ENTIRE birthing process.
* Midwives will allow you to labor at home until you are ready to go into the hospital (in areas where home birth is not available). I labored at home until I was nearly 7CM dilated. This allowed me to get through the majority of my labor in a place where I was comfortable, I could go into my shower and deal with my labor in my own way. (If you have a single stall shower, and are preggo.. contact me, I'll give you an AWESOME tip to help with Back Labor). Then, there wasn't the hours and hours and hours in the hospital, in an uncomfortable bed, being stared at, poked at, and prodded, waiting for baby to arrive. I showed up at 11PM, and Baby was born at 5:30AM.

I think the issue so much isn't LOCATION of care, but QUALITY of CARE. Rather than being a number, or 'another pregnant whiner' (like I felt at the OBGYN's office) I was a person, who was about to give birth. I felt as though I knew what was going to happen and had some control in how I was going to deal with it. I wasn't told what was going to happen to me, I was allowed to dictate what was going to happen to MY body and MY baby (within reason). Period. Doctors don't let you do that. Because Homebirths are taken care of by Midwives and not doctors, more people are taking that route, because they LIKE THE TREATMENT better.

Why would someone choose to give birth at home vs. giving birth in a hospital? Because. It's nicer at home. Home is comfortable. The beds are comfortable. Your family is there to help. You can control your environment by dimming lights, playing music, doing whatever you need to do to help with pain managment.. That isn't always available in the sterile, cold environment that most hospitals provide... Oh yeah, and WOMEN HAVE BEEN GIVING BIRTH AT HOME FOR THOUSANDS OF YEARS, AND STILL DO IN MANY OTHER COUNTRIES..

Our country has an EXTREMELY high infant mortality rate.. I believe it is not because of where we give birth, but because of the way we as pregnant women are treated by our doctors... If doctors would start treating us as people going through a natural function, rather than a number with a 'condition' requiring 'treatment' then, women would be more comfortable with giving birth. Women would be less frightened about what is happening to them, and they would relax more, they wouldn't be stressed about the pain (that is totally managable by most people in most circumstances if they were educated about it). FEAR causes PAIN to be worse.. and I didn't have a doctor that has EVER eased my fears about anything. My midwife, on the other hand... She was there to hold my hand and help me through the pain and the fear.

To sum this up, I think that the MAJOR issue here is the way DOCTORS are treating their pregnant patients. I have seen it, heard it, and experienced BOTH ways first hand. I prefer the midwife approach whole-heartedly. I believe that if women would get over the belief that Midwives are all natural, no drugs only types of people, rather than someone who is there to give you the best and safest birth experience possible, they would choose a midwife over a doctor nearly every time.

Submitted by MommaMary on Thu, 02/14/2008 - 12:51
 

Abso frikkin lutely!

A woman should have a choice in her birth style depending on health etc...
She should be able to choose home, hospital, midwife or OB...

But everyone of those choices has to be safe and with respect and honesty and the woman has to be treated like a human who knows her body and her instincts and feelings about her state of labour or the state of her child HAS to be respected.

I am helping our local opposition MLA in his campaign to show how thoughtless and careless hospitals can be.

This after a stillbirth at fullterm AFTER the woman went to the doctor about leaking amniotic fluid days before. Nothing was checked.

I delivered my 26 week stillborn son alone with my dh and mom...no nurse.

This is why women are fed up with the hospitals and should be given more choices....but the hospitals need to buck up and improve L&D

I am horrified by how much women seem to be being hooked up to drugs for no reason except that she is in labour....women given medical inducements when they are not over due....it astounds me.

You are more than welcome to pain relieving drugs..it is a choice..but all the other bells and whistles totally cater to the doctors schedules and not the baby's.

Look for me at http://crunchycarpets.com or check out the ladies at www.wetcoastwomen.com

Submitted by Crunchy Carpets on Thu, 02/14/2008 - 13:25
 

The system needs an overhaul

CC -

I'm so sorry for your loss.

I agree with you and MommaMary that there needs to be a huge shift in the level of care and in how the medical establishment views birth. Despite what the ACOG says, I don't believe they view birth as a normal physiological process. Labor and birth is something to be managed. I found this quote on Women's Health Channel: "An obstetrician is a physician who has successfully completed specialized education and training in the MANAGEMENT of pregnancy, labor, and pueperium (the time-period directly following childbirth)." (emphasis is mine)
It may not entirely be the fault of the OB-GYNs. I believe they are totally over-scheduled and it's no wonder that many of them want to manage birth so that it fits more into a 9-5 schedule. If they are up all night with patients giving birth, how can they be expected to get up the next morning to go to appointments and/or do scheduled surgeries? Which is why I believe birth needs to go back to the midwives - not just with home birth but hospital birth too (with low risk pregnancies). Midwives could take the burden off the OB-GYNs who would then be free to practice their specialty - pathology and surgery.

Amy
Crunchy Domestic Goddess
BlogHers Act contributing editor

Submitted by Amy Gates on Fri, 02/15/2008 - 15:25
 

Had a HomeBirth and LOVED IT!!!

As someone who has done the whole range of birthing experiences--c-section, VBAC hospital, and home birth, I can absolutely say that our home birth was the most comfortable, safest, natural, and best option for us. Period.

My first birth started with a midwife in a freestanding birthing center, but ended up with a cesarean section in the hospital. It was the right choice, our midwife was with us, and we felt great about.

The second birth was a VBAC with a midwife. Due to increasing restrictions on VBACs, we were not allowed to birth in the birthing center, we had to birth at the hospital. Still our midwife was there and we loved the experience. But, we checked out a few hours after the birth because we were tired of being poked and prodded by staff who interrupted natural mama-baby bonding time.

Third and final birth was a homebirth with a midwife. I was so relaxed and comfortable, it took me hours to realize I was in labor. People have asked us if we felt like we were risking the baby's life, or mine, by doing a homebirth. On the contrary--we felt like we got the BEST medical care because the midwives were focused solely on the baby and I. Midwives are highly trained professionals, they are prepared to deal with emergencies, and the ambulance was only a phone call away if we really needed it. But, we didn't.

A large part of homebirth is the preparation months ahead. We had to have all of the birthing supplies, a birth plan dealing with all contingencies (including emergencies) ready well ahead of our birthing time. We had routes planned out to the hospital of choice if we needed it, alerted our local ambulance service that we were doing a homebirth and that we just wanted them to be aware, and knew what to do and where to go in case we needed transport. All of that prep work ahead of time made it easier to forget about it when birthing time came. Everything was covered, we didn't have to worry or be taken by surprise. Instead, we had a nice relaxed birth, where our baby and I were well taken care of. Nature as it should be, imagine that? Homebirth, when properly practiced, with experienced midwives is safe and the best care around. Fear should not be part of making birthing choices.

"No, I'm not pregnant, but thanks for asking!"
www.theredheadwrites.com

Submitted by LaughingRedhead on Fri, 02/15/2008 - 02:20
 

VBAC restrictions and home birth prep

LaughingRedHead -

Thanks so much for sharing your experiences.

You bring up a very valid point in that women who want VBACs (and who should totally be allowed that choice) do not always have the option of having one due to hospitals' or birthing centers' restrictions. (The hospital in my own town no longer allows VBACs.) So these women who want to avoid another surgery then may have no other option than to give birth at home, which seems to indicate another excellent reason for regulating and licensing CPMs, so they can attend these births legally and not have to fly off of the radar. If there is legalization then maybe they could even have physicians to back them up if needed. That would truly be in the best interest of women's health.

Thanks for pointing out all of the research and preparation as well that goes into having a home birth. I don't think everyone realizes that there are plans in place for the event of an emergency, however unlikely it may be. It is also worth noting that because CPMs deal with normal (unmedicated) birth all of the time and because they are with the woman while she is in active labor, they are very tuned into when something deviates from normal, often well before it is a true emergency, allowing ample time for a hospital transfer.

Amy
Crunchy Domestic Goddess
BlogHers Act contributing editor

Submitted by Amy Gates on Fri, 02/15/2008 - 15:47
 

More statistics requested

I too am a lover of mother nature and feel that the most natural way to do things is by far the best in most situations. I read the statistics about higher risk of neonatal death in home deliveries, but have to ask where are the statistics about delivery and immediate peri-natal problems that go untreated and that result in long term disibilities not death? I worked in a children's hospital for over ten years as a speech therapist and I would guess at least half of the children we worked with were being seen due to birth trauma causing a lack of oxygen to the brain (cerebral palsy). I know that this can happen whether in a hospital or not, but I would like statistics showing that it is more or less likely to be a concern with home birth. Anyone have any ideas?
I also do not believe that the physicians are solely to blame for the desire for hospital births I think that many of them agree that less medical intervention is better. None of them WANT to risk a woman's life by performing an unnecessary c-section, just as none of them WANT to lose their license and career because they made the most informed decision they could at the time, it just happened to be wrong. If the ACOG endorses then it will ultimately be to blame also.
There has to be a middle ground and it seems that that must include CNM's CPM's, OB/GYN, Local Hospitals and Insurance companies all working together to support a pregnant woman.
As someone with 2 c-sections, one emergency and one by choice, all we all really want out of pregnancy is a healthy little one to hold so lets try to get some cooperation amongst the providers to get us there.

Submitted by JenInShanghai on Fri, 02/15/2008 - 18:46
12next ›last »