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Home Birth In a Risk Society: A Commentary by Sociologist Barbara Katz Rothman

February 4th, 2014 by avatar

By Barbara Katz Rothman, PhD

Today, I am delighted to share with you an essay on risk written by sociologist and author Barbara Katz Rothman, PhD.  There has been much discussion and debate on two papers just published in the Journal of Midwifery and Women’s Health, using the MANA Stats V2.0 data from the Midwives Alliance of North American. You can find these two papers and a research review by Judith Lothian published on January 30th on Science & Sensibility. – Sharon Muza, Community Manager, Science & Sensibility.

We live in what Social Scientists called a ‘Risk Society.”[i] If you simply google “risk and birth,” you get over 402 million ‘hits.’  So no question, birth is understood as  having risks, creating risks, being risky business indeed.  But not the riskiest of businesses – Google “risk and food,” and you get almost twice as many hits – over 746 million. That doesn’t feel right somehow – pregnancy and birth are always and everywhere in our world understood as risky; food not so much.  I nibble some snacks as I write, sip some tea – are you worrying for me? Wishing me luck with that?  Thinking about the odds of food poisoning? Insecticide exposure?  the long term risks of diabetes, joint pain, heart troubles, cancers that might be flowing forth from the snack choices I am making?

image: www.thinknpc.org

image: www.thinknpc.org

 

And what about those snack choices?  Do they not carry much of the same moral weight that pregnancy choices make — if I tell you it’s green tea and carrots, or if I tell you it’s a honey chai latte and multigrain crackers with organic almond butter, or if I tell you it’s a Nestle Iced Tea and Oreo cookies – do I not create different images of myself as a risk-taking or risk-sparing person, even as a more or less ‘good’ and responsible person?  These are of course the arguments that Risk-society thinkers have been addressing: the risks we perceive and the risks we take are judged, by ourselves and by others.

In birth, few choices have been as freighted with the language of risk and responsibility as that of home birth.

The irony here is that birth moved into the hospital with all of the data showing us that move increased risk; and all of the research we have now still shows us that hospitals present unique and particular risks for birth. Birth moved into the hospital long before the era of Risk – that move was done in the era of Science.  The same science that covered our kitchens in white laboratory-style paint and tiles, that replaced local baking with packaged white bread made out of mass-milled white flour, that created industrialized systems to raise cheap meat at whatever costs to health of humans or animals, that moved fruits and vegetables from fresh to canned – that same science that created the industrial diet of the turn of the century, created the industrial birth.

image: sharon muza

image: sharon muza

When I wanted a home birth almost forty years ago, I knew nothing of midwifery. I just assumed that obstetricians had the necessary knowledge and skills to deliver babies (and yes, I called it ‘deliver’) and that those skills could be used in my bedroom as well as in a ‘delivery room.’  Over the course of my scholarly work in the years following, I learned how wrong that was.  Home birth involves a set of skills, practices and competencies that people trained in hospital birth most often never have learned.  Thus the MANA data is not merely a comparison of place: What we are seeing in this data set is a study of midwifery-led care, or as Ronnie Lichtman has called it[ii], midwifery-guided birth, birth in settings where midwives and the women they are guiding have control over practice.

MANA’s data and these articles are showing us that the United States, for all of its problems, is not exceptional:  Fully autonomous, informed midwifery care provides better birth outcomes than does care under Obstetrical management.  Obstetrics and Gynecology is a surgical specialty, magnificently equipped to manage particular illnesses and crises, but neither the discipline nor the hospital settings it has developed for its practice are appropriate for normal, physiologic birth.

Research on women who choose home birth, as well as midwives who provide it, show that their concerns go beyond the risks of what is often called the ‘cascade of interventions’ that follows medical management, leading as it so often does to cesarean section.  In addition to the well-documented iatrogenic risks, they address risks of the hospital itself, what are called when looking at infections, ‘nosocomial’ risks. They were concerned with errors that are made when people are managed in what is essentially a factory-like setting: risks of overcrowding; risks of exposure to others and exposure of self.[iii]

Hospital-industrialized births demand standardized care. Consider something as mundane and yet intrusive as the vaginal exam.  Medical guidelines, the medical story, is that such exams are necessary to determine labor and its stages.  That of course is absurd.  Do you really think that an experienced midwife, someone who has attended hundreds or thousands of births cannot tell if a labor is established without a vaginal exam? What a midwife needs that exam for is to document, not to establish the labor.  Those exams are not only intimate and intrusive, but for women with histories of sexual abuse especially, can be experienced as traumatic.[iv] For all women, raised with ideas of bodily privacy, integrity and what used to be called ‘modesty,’ such exams at a moment of vulnerable transition are problematic. Done for reasons of institutional management and control, they are one more interruption and create risks of their own. Particularly in hospital settings, vaginal exams are one more occasion for the introduction of nosocomial infection.

Managing the management thus becomes necessary in hospital settings: – midwives use the vaginal exam to create the story that will be most in the woman’s best interests, and occasionally in the midwives’ own best interest.  Midwives are thoughtful about when they measure because, for example, they are hesitant to start the clock too early.  In such care, what midwives are trying to minimize is not the risks of a prolonged labor, but the risks of intervening in a labor medically defined as prolonged.

It is reasonable to talk about how recent this language of ‘risk’ is in pregnancy and in birth – but the language of danger, that which we are in risk of, has long been an accepted part of birth.  Calling it “Risk” is adding the numbers – sure there are dangers, but precisely what are the odds? That there are dangers in pregnancy and in birth, and that they can be avoided or overcome, this is not news.  Dangers, disasters even, could happen in the best and healthiest of pregnancies and births.  The difference perhaps is that now there is no such thing as a healthy pregnancy and birth.  There still is an understanding of such a thing as a ‘healthy meal” and even a “healthy diet,’ but no longer, it seems to me, a healthy pregnancy – the best you can hope for is a low risk pregnancy.

It is not that midwives do not have understandings of danger and knowledge about ways to avoid danger, including the dangers of prolonged labors.  That is precisely what midwifery has been throughout time and across place: the development of a body of knowledge and skilled craftsmanship to navigate the dangers of childbirth.  All of that knowledge was discounted with medicalization.

Scientific or ‘Medical’ knowledge is accepted as real and authoritative; other knowledge is reduced to ‘intuition’ or ‘spiritual knowing,’ made all but laughable.   But when a baker adds a bit more flour because the dough is sticky, is that ‘intuition’?  Or is that knowledge based on craft, skill, deep knowledge of the hands?  When a violin-maker rejects a piece of wood in favor of one lying next to it that looks just the same to me or to you, is that ‘intuition’?  Or experience, skill and craft?  And when a leading neurosurgeon examines a dozen stroke patients who all present pretty much the same way on all of their tests and feels hopeful about some and concerned for others, is that ‘intuition’?  Or knowledge based on experience, using a range of senses and information that may not be captured in the tests?

In hospital settings, midwives do not have the authority to use their knowledge fully in the woman’s best interests.  And therein lie the risks.

And finally, it would be helpful to put these risks in contextIf safety were our real concern, if saving the lives of babies and of mothers were the driving force, then there are a number of changes we would make immediately.  We would require helmets for people in cars, something we know would save lives each week.  We would lower the speed limit in urban areas, and end driveway parking in suburbs. To suggest such things makes one look crazy – crazier than suggesting home birth.  But it most assuredly would protect children. If saving babies were our concern, we would invest in public housing, and in the food system.  These are large scale changes that would save far more people than anything that happens in those few hours of late labor to early neonatal period, the 24 or so hours of hospitalization that is now being debated.

Clearly something more or other than saving babies is at stake.

References

[i] Beck, U. (1992). Risk society: Towards a new modernity (Vol. 17). Sage.

[ii] Lichtman, R. (2013). Midwives Don’t Deliver or Catch: A Humble Vocabulary Suggestion. Journal of Midwifery & Women’s Health.

[iii] Katz Rothman, B., (2014) Risk, Pregnancy and Childbirth, Risk, Health and Society, edited by Alaszewski, Intro by Barbara Katz Rothman. Volume 16.1, forthcoming.

[iv]  Adult manifestations of childhood sexual abuse. Committee Opinion No. 498, American College of Obstetricians and Gynecologists. Obstet Gynecol 2011: 118:392-5.

About Barbara Katz Rothman

image: Barbara Katz Rothman

image: Barbara Katz Rothman

Barbara Katz Rothman, PhD, is Professor of Sociology, Public Health, Disability Studies and Women’s Studies at the City University of New York, and on the faculty of the Masters in Health and Society at the Charite in Berlin, the University of Plymouth in the UK, and the International Midwifery Preparation Program at Ryerson University in Toronto Canada. Her books include In Labor: Women and Power in the Birthplace, The Tentative Pregnancy: How Amniocentesis Changes the Experience of Motherhood, Recreating Motherhood, The Book of Life: A Personal and Ethical Guide to Race, Normality and the Human Gene Study,  Weaving A Family: Untangling Race and Adoption and Laboring On: Birth in Transition in the United States.  Dr. Katz Rothman is the proud recipient of an award for “Midwifing the Movement” from the Midwives Alliance of North America.

Cesarean Birth, Childbirth Education, Do No Harm, Evidence Based Medicine, Guest Posts, Home Birth, informed Consent, Maternal Quality Improvement, Maternity Care, Midwifery, New Research , , , , , , , , , ,

  1. avatar
    Amanda
    February 4th, 2014 at 06:06 | #1

    Wonderful article!! Thank you for sharing your thoughts and perspective. There are so many more factors that play a role in maternal and neonatal health. There are lots of areas of safety in our society that have room for improvement and many different ways to keep birth safe and sacred for families.

  2. avatar
    Robin Hutson
    February 4th, 2014 at 06:10 | #2

    Thank you so much for elevating this discussion beyond the myopic limits the internet debates fuel again and again. I cannot imagine how beneficial it would be for those who spend so much energy trying to declare homebirth “unsafe” to recognize the need for a thoughtful, integrated system of care, where the proven benefits of midwifery led care in all birth settings are allowed to address our maternity care crisis.

    Until then, I think all those who waste so much internet time declaring home birth unsafe must drive around wearing helmets.

  3. February 4th, 2014 at 07:38 | #3

    Thanks for this thoughtful commentary! You make great points about how subjective our reaction to known risks can be (birth vs food vs transportation), and I appreciate you shinning a brighter light onto the other factors that come into play when considering ‘industrial births’ in the hospital setting.

  4. avatar
    Lauren W.
    February 4th, 2014 at 07:53 | #4

    Thank you for this, very well written!

  5. avatar
    CRiley
    February 4th, 2014 at 08:28 | #5

    It’s refreshing to read this essay that speaks so well to the current deabte on out of hospital birth. As a mother that is not a professional, but fascinated with the entire topic, it’s wonderful to have this fresh perspective that does not rely on statistics and data but still captures the main point. I’m sure other parents will appreciate this essay in their search for meaningful and accurate information regarding their choices in birth.

  6. avatar
    Ashley
    February 4th, 2014 at 09:46 | #6

    This is a great perspective! I find it very frustrating that our society focuses on the risks of homebirth, but sweeps risks of hospital birth under the rug. Statistically far more people are negatively impacted by hospital risk than home risk. Thank you!

  7. avatar
    Another Liz
    February 4th, 2014 at 10:15 | #7

    “If safety were our real concern, if saving the lives of babies and of mothers were the driving force, then there are a number of changes we would make immediately.”

    Of whom are you speaking when you write this?

  8. avatar
    Jesse Garon
    February 4th, 2014 at 11:15 | #8

    But, being born is by far the riskiest single event of the average person’s life (outside of, perhaps, fighting in an active combat zone). However much fluff you want to put around it, babies are a lot more likely to die at home birth than in a hospital, particularly if the birth attendant does not have the educational equivalent of a CNM. I guess I’m not sure what the point of this article is, except to try to convince women not to use their brains and look at facts to make rational decisions.

  9. avatar
    Scientist Mom
    February 4th, 2014 at 11:25 | #9

    If you believe a neurosurgeon uses his intuition in examining patients, what makes you so sure obstetricians never use experience and intuition? In my personal experience, they do!

    If you want real numbers, the probability of a baby dying in or shortly after a low-risk home birth is (using the recently released numbers) almost exactly the same as the probability of dying in a motor vehicle accident at any time from birth up to the age of 25. It’s seven times greater than the probability of a child dying in a car accident before the age of 10. And people ride in cars every single day.

    So yes, even compared to car accidents, the leading killer of children in the USA, the risks of home birth are significant.

  10. avatar
    rroonie
    February 4th, 2014 at 11:42 | #10

    The neonatal death rate for low risk women is equal between homebirth and hospital birth. No difference. Again, I repeat: there. is. no. difference. The stats show this and it is not disputed. The neonatal mortality rate is one of the best ways we can gauge the level of care provided by midwives and doctors. If the neonatal mortality rate is low, you can safely assume the obstetric care is good and the method of birth is safe. The intrapatum mortality rate for low risk homebirth is 0.8/1000, for birth center birth with a CNM it is 0.5/1000 and for hospital birth it’s not known for sure but assumed to be 0.3/1000. These differences are very small. Also, homebirth has a cesarean rate of only 5% while hospital birth has one of 35% or more. Homebirth is safe for low risk women. Period.

  11. avatar
    Jesse Garon
    February 4th, 2014 at 12:12 | #11

    @Ashley

    How so, Ashley? Are you familiar with the concept of rate?

  12. avatar
    Wendy
    February 4th, 2014 at 12:48 | #12

    This was a wonderful article. Especially for someone like me, who has experience in both hospital and home birthing. 1. Forced C-Section, 2. Pitocin induction leading to vacuuming, 3.& 4. Home Birth with absolutely no intervention & benefits to ME, ME the woman, mother that I cannot even put into words, that there are no statistics for. I knew that my C-section was wrong, warped. I knew that demanding I be allowed to vbac with my second what the right thing to do, and I knew that the procedure leading to that vaginal birth was wrong. I KNEW, with every ounce of my being, that birth was so so so much more than any institutionalized practice could even admit. And so I stayed home, with an experienced, seasoned, wonderful, patient, knowing midwife. And the level of care is not comparable, there is no comparison. And if you research, to the best of ability with the information available, regarding the safety of home birth vs. the safety of hospital birth, a wise person knows instinctively, that the risk of trouble increases dramatically in the hospital. Period, I don’t even understand how this is debatable honestly.

  13. avatar
    Danielle D
    February 4th, 2014 at 13:11 | #13

    Re: “The neonatal death rate for low risk women is equal between homebirth and hospital birth. No difference. Again, I repeat: there. is. no. difference. The stats show this and it is not disputed.”

    If this were true, you would not be all standing about an applauding an article telling us that the concept of risk is unimportant. This is astounding to me. We should not be ruled by fear, but we should take a rational note of risk and respond appropriately if we care about outcome. And the outcome of pregnancy and birth – a live, happy, flourishing baby – is the outcome we want. Some risk is inevitable, but unnecessary risk is unacceptable–unacceptable to the woman who is interested in preventing problems as well as she can, and unacceptable to professionals whose sole duty and obligation it is to do the best they can to promote the health and safety of others. We should only trade higher risk for something that is “worth it.” Is the “comfort of home” and some scented candles worth it? For some people, home birth might be worth it. But they can’t know this unless they understand what the risks are. That means you need to acknowledge them and stop pretending that none exist or that the concept of risk is unimportant.

    There is tremendous statistical evidence showing that there are added risks to home birth. You can find it the Cornell study just announced, but not only there. It is even in the MANA numbers, if you look at the numbers they reported, if you compare them to proper comparison groups (MANA didn’t). (And while we are on it, MANA used data reported on a voluntary basis only – what a silly way to gather data – I wonder what you would say if hospitals did this.). The State of Oregon didn’t find particularly good results among its documented home births, either. In any case, this is contested territory at a bare minimum. It is not case closed.

    Home birth is somewhat safer than it otherwise would be because we have an elaborate medical system able to handle transfers when things go wrong–and they frequently do. But there is automatically going to be some added risk when the time factor is added. How much we can debate. But it’s there. In the future, home birth may also be more or less safe than it is today in absolute and relative terms. But that depends on the practices of midwives, and whether this “profession” is going to rigorously review its practices — and yes, RISKS — to improve outcome. Are you going to do this?

    If a birth center or accommodating hospital could provide better care, would you change your site of practice?

    I hope the answer is yes.

  14. avatar
    Danielle D
    February 4th, 2014 at 13:28 | #14

    On a couple of other points, if you don’t mind my adding an addendum to my other comments:

    The article asks, “If safety were our real concern, if saving the lives of babies and of mothers were the driving force, then there are a number of changes we would make immediately.” The author then goes onto to offer some examples that are “laughable”. But is that not actually what we should be doing, and sometimes are doing? If we can adjust the speed limit on certain street and save lives, should we not consider it? If we can modify how we drive or build cars to improve safety, do we not change manufacturing requirements and driving standards? If we can provide healthier food to people, should we not consider it? We do not always do every single little thing we possibly can — because sometimes there are conflicting imperatives, sometimes because we fall down on the job–but the conversation about risks and benefits, investments and returns, and collective values is always worth it. It is never laughable. That is why risks matter and need to be apprehended. They are not the whole conversation, but they are part of the conversation.

  15. avatar
    Sarah
    February 4th, 2014 at 13:46 | #15

    @rroonie
    You can repeat it as many times as you want, but it’s not correct.
    1) First of all, even if your numbers were right, which they are not, you are brushing off a nearly 3x higher death rate as “very small.” This means for every 10,000 babies born at home, 5 babies would die needlessly, because they would have survived in the hospital. And this is with distorted and miscalculated stats. This may not be a big deal to you, but women deserve to hear the truth, rather than being told “there.is.no.difference.”
    2) Your 0.85/1000 intrapartum death rate comes after eliminating higher risk factors from the set, compared to the Birth Center and hospital data, which do not. That is a distortion.
    3) You should look at all the intrapartum + neonatal data. Early and late neonatal deaths for a comparable low risk group of women in hospital are ~0.4/1000. Intrapartum deaths are not in CDC stats, but are estimated in other studies to be 0.1-0.3/1000 across all gestational ages and pregnancy complications. So, assuming 0.3/1000 for low risk term pregnancies is quite a stretch.
    4)Even if you take your distorted number that post facto weeds out the higher risk women, AND exclude lethal anomalies, the number is still 0.85 + 0.29 + 0.23 = 1.37/1000, The number for hospital deaths, including higher risk factors, including lethal anomalies, and including your inflated intrapartum rate, is still ~0.7/1000 or HALF that of your set. And this is with all your unjustified somersaults.
    A more accurate comparison would pit a hospital number of ~0.5/1000 against the comparable homebirth death rate of 2.59/1000, around 5x as high. And this with 20-30% of the voluntarily reported data from homebirth.

    Homebirth in the US is NOT as safe for the BABIES of low risk women. Period. If women are willing to shoulder that higher relative risk because they see perceive it as a low absolute risk, that is fine. But they deserve to be told the truth. And they should be told that breech, VBAC, multiple gestations, GDM or pre-e make them poor candidates for homebirth.

  16. avatar
    Jesse Garon
    February 4th, 2014 at 14:29 | #16

    @Wendy

    1) you had a forced c section? As in they physically restrained you without your consent? Because if so you’d have won one heck of a lawsuit.

    2) you keep talking about the benefits to YOU. Is birth really all about you? Or is it actually about what’s safest for the baby? Just so we are clear.

  17. avatar
    rroonie
    February 5th, 2014 at 06:49 | #17

    Ok, Sarah. Let’s compare the numbers from the birth center study which ONLY includes low risk women and also includes intrapartum mortality and neonatal mortality rates. The birth center study has NOT been criticized and is well done study showing the safety of certain free standing birth centers that follow strict guidelines. Even opponents of homebirth support the findings of the birth center study and admit it shows that births at those birth centers are safe.

    Stats from the birth center study: (low risk women)

    Neonatal mortality: .38/1000
    intrapartum mortality: .5/1000

    MANA stats: (low risk women)

    Neonatal mortality: 0.41/1000
    intraprtum mortality: 0.8/1000

    There is no statistical significance between the two. If critics admit that accredited birth centers in the US are safe then they MUST admit that homebirth is safe as well since the numbers are almost EXACTLY THE SAME.

    Homebirth is safe for low risk women.

  18. February 5th, 2014 at 07:11 | #18

    Thanks Barbara–a very articulate and thoughtful commentary on “risk” and the ethical principles of “autonomy”–the right to self-determiantion in medical decision-making. I often feel the bottom line of the controversery about home birth and midwife-guided care is contained in this nugget from your commentary: “That is precisely what midwifery has been throughout time and across place: the development of a body of knowledge and skilled craftsmanship to navigate the dangers of childbirth. All of that knowledge was discounted with medicalization.” Medicalization, indeed! I imagine most people in the U.S. can see that the “medical delivery business” has changed the character of the health care industry to focus less on “health” and “care” and more on “industry.” It requires consumers of health care to be vigilant regarding their choices of birth place and birth practitioners, and well-infomed regarding making decisions for themselves & their familes. Your piece puts “risk” and “decision-making” regarding the safety of planned home birth in the context of the larger issue–and the imperative–of truly ensuring safety for mothers & babies in the childbearing year. Thank you.

  19. avatar
    Jesse Garon
    February 5th, 2014 at 14:58 | #19

    @Geradine Simkins

    So, are you saying that the higher risks of death at home birth with CPMs are worthwhile in the context of some larger tradeoff in reduced maternal or infant mortality in the first year that CPM homebirth provides? If so, could you expand on that thought and the evidence behind it?

  20. avatar
    Danielle D
    February 5th, 2014 at 15:56 | #20

    @Geraldine-

    I am not sure I understand why you think midwives recommending homebirth are necessarily better at following women and responding to their needs throughout pregnancy. Perhaps that is sometimes true, if midwives make good on their interest in the mental/spiritual/personal aspects of pregnancy and birth. But I suspect many people have experienced both compassion and interest from OBs and nurses/midwives in the “institutional” settings of clinics and hospitals, as well as close following of their pregnancy. That was my personal experience at a clinic associated with a large research hospital. Even though I was low risk, my OB was very personable and interested. The nurses in delivery were wonderful and kind. The hospital even connected me with a doula-in-training who attended the birth (but I didn’t find that she met any needs not already being addressed pretty well. She was a particularly cheerful face).

    Isn’t close care, holistic care even, possible in many settings? I think this can be accomplished/improved across the board.

  21. avatar
    Danielle D
    February 5th, 2014 at 16:30 | #21

    @rroonie

    Let me see if I am following your numbers correctly:

    You are citing birth center stats for low risk women to be .38/1000 plus .5/1000m, or .88/1000 combined.

    You cite homebirth stats of .41/1000 plus .8/1000 (which is optimistic at best given the data collection method). Combined thats 1.21.

    In what universe is .88/1000 and 1.21/1000 the same risk? (And is the hospital rates are even lower.)

    So it’s not the same. In terms of risk: hospital>birth center>homebirth.

    Should we just say this in a straightforward way? Then women can decide whether differences in risk between particular options are worth it to them.

  22. avatar
    Jeff Olejnik
    February 5th, 2014 at 17:36 | #22

    Come on Danielle, “they MUST admit that homebirth is safe as well since the numbers are almost EXACTLY THE SAME”

  23. avatar
    Sarah
    February 5th, 2014 at 19:32 | #23

    @rroonie
    Unfortunately, your numbers are still not right. First of all, the birth center stats did record all neonatal outcomes through 4-6 weeks – they just didn’t have any late neonatal mortalities. So it would be appropriate to compare the 0.40/1000 to 0.41 + 0.35 = 0.76/1000 excluding lethal anomalies. Second, it is NOT appropriate to take your lower risk 0.85 number from the MANA study, for two reasons: 1) part of the reason that birth centers are safer is that they generally have better standardized protocols for defining women as “low risk” and for transferring them to more appropriate care when necessary. Homebirth does not have this; and 2) the birth center set does still include some women w/ TOLAC, breech, and pre-e, though a smaller % than the homebirth set. So the original 1.3/1000 number is more appropriate.

    So that is:
    Birth Center – 0.47 + 0.40 + 0 = 0.87/1000
    MANA – 1.3 + 0.41 + 0.35 = 2.06/1000

    Once again, a >2.5x risk. Even if we took your fixed up “low risk” intrapartum number it would still be 1.61 vs 0.87 or about double the risk. And again, with only 20-30% of voluntarily reported homebirth data.

    The low risk hospital numbers are even better. As I said before, they would be closer to ~0.5/1000, INCLUDING lethal anomalies, with homebirth being at least a 3-4x risk, EXCLUDING lethal anomalies.

    Again, just repeating over and over that there’s no difference doesn’t make it true. Homebirth is not AS safe for babies. To the tune of 3-5x times in nearly every study, including this one. If women choose to take on that risk because they see the absolute risk as small and choose to focus on the benefits, then that is their decision. But they need to be informed, NOT lied to.

  24. avatar
    Another Liz
    February 6th, 2014 at 05:48 | #24

    Ya know, there really is no such thing as EXACTLY THE SAME when using statistics to describe differences in samples. Statistics are used to calculate the probability that the two results are different. And whether x/1000 is same or different than x.4/1000 or 4.x/1000 requires a little further statistical analysis than simply declaring something is EXACTLY THE SAME.
    p-values seem to have dropped off the face of the Earth, and that’s a shame. I would have enjoyed seeing some p-values in the MANA study.

    Birth Center – 0.47 + 0.40 + 0 = 0.87/1000
    MANA – 1.3 + 0.41 + 0.35 = 2.06/1000

    Maybe I’m a complete dolt, but without a test: a p-value, a CI, something – there’s no way tell if these numbers – as they are presented above – represent a true difference or random variation of the same outcomes.

    I’m not saying this to defend any side or another, but only to offer my opinion that I’d like to see some more informed, reasoned discussion around this topic. Statistics don’t lie, but they never make a claim of 100%, either.

    Also, for the MANA folks, et al. The identified, probable increased risk of birth injury or death, even if the absolute risk is small, is still reason for action to be made on a professional level to reduce these risks.

    “Clearly something more or other than saving babies is at stake.”

    I’m looking at you, MANA.

  25. February 6th, 2014 at 07:40 | #25

    Another Liz :
    Ya know, there really is no such thing as EXACTLY THE SAME when using statistics to describe differences in samples.

    Exactly. “Although you cannot statistically compare this study’s results to hospital birth, these results can be used to help in the informed consent process for women who are considering home birth.” (Borrowed from “My thoughts on the U.S. Home Birth Study” by Rebecca Dekker, PhD, RN, APRN of http://www.EvidenceBasedBirth.com) Rebecca’s full note is located here: https://www.facebook.com/notes/evidence-based-birth/my-thoughts-on-the-us-home-birth-study/597826893629487

  26. avatar
    Danielle D
    February 6th, 2014 at 07:50 | #26

    “Also, for the MANA folks, et al. The identified, probable increased risk of birth injury or death, even if the absolute risk is small, is still reason for action to be made on a professional level to reduce these risks.”

    The absolute risk for any given individual may be OK in their estimation; they should be told the risk is there and then they can factor that into the complex decision about chosing among health care options.

    But the professionals’ imperative is different. If you service thousands of people over your career, these differences in outcomes mean that you may have several additional deaths of babies under your care than necessary. That’s no small matter.

    Even when providers and home birth mothers acknowledge and accept some increase risk in trade for other benefits of the home setting, within the limitations of that site there should be review, analysis, and rereview of the practices used by midwives to ensure that all due diligence is taken to detect and respond to problems. It still won’t be as safe as a hospital or birth center, but it can be more or less safe than it is today. That depends on the ethics and self-reflection of home birth practitioners.

  27. February 6th, 2014 at 07:53 | #27

    Please, unless you have new information to add to the comments, re-hashing of how to calculate some of the statistics has run its course. I want to keep the dialogue open but don’t want to have this go in circles. Repetitive comments on items already well discussed will be removed. – SM, Community Manager

  28. avatar
    Another Liz
    February 6th, 2014 at 08:45 | #28

    Thank you, Danielle D, I appreciate your perspective regarding decision making whether it is by the individual client, or by the professional. I agree. If I am a member of a credentialed profession, I should be expected to uphold professional standards of practice which are based upon evidence of safest practices.

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