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Flaws In Recent Home Birth Research May Mislead Parents, Providers

September 26th, 2013 by avatar

by Wendy Gordon, CPM, LM, MPH, MANA Division of Research, Assistant Professor, Bastyr University Dept of Midwifery

Midwife Wendy Gordon shares with Science & Sensibility readers why the recent home birth research using 5 minute Apgar scores does not produce reliable data that consumers can use to make a decision on where they would like to give birth.  Have you had a chance to read the study?  What were your conclusions? See if you agree with Wendy or had some different thoughts.  Share your opinion and thoughts with us in the comments section.  Thank you Wendy for providing information that can help us to assess the study and understand it better. Sharon Muza, Science & Sensibility Community Manager

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© http://www.mybirth.com.au/

A recent press release by the authors of a new study raised alarming headlines in a few media outlets, suggesting that babies born at home had a 10-fold higher death rate than babies born in the hospital. I’ve written previously about reliability concerns with the use of birth certificates in this study. In this post, we’ll go more in-depth with some of its other flaws. Let’s start with the fact that the authors did not examine stillbirths.

Apgar scores and stillbirth

The new study by Grunebaum et al. (2013), in press with the American Journal of Obstetrics & Gynecology, examined birth certificate data for almost 14 million births between 2007 and 2010 looking for differences in outcomes between home and hospital births. They did not look at “stillbirths,” perinatal, intrapartum or neonatal deaths. They looked at 5-minute Apgar scores of zero, and led the readers of their press release to believe that this meant that the babies died during or shortly after labor, due entirely to their choice of birthing at home.

When we examine a little more closely what it means to have a 5-minute Apgar score of zero, we might find that it does include some babies who died shortly after birth. We might also find a number of babies who had lethal congenital anomalies, who would not have survived no matter where they were born or who attended the birth; there may be important differences between home and hospital populations with regard to whether these anomalies were detected prenatally and whether parents changed their birth plans because of it. There may also be some babies who were successfully resuscitated after the 5-minute Apgar score was assessed. While the authors conceded in the study that their analysis could have included these births, as well as babies who died before labor even began, the terminology used in their press release is highly misleading.

A rigorous study that actually examined deaths would have excluded births with outcomes that had nothing to do with place of birth or attendant. Several well-designed studies have done just that and have found no differences in mortality rates between planned home and hospital births, and often fewer low 5-minute Apgar scores among planned home births attended by midwives (Ackermann-Liebrich et al., 1996; Olsen, 1997; Janssen et al., 2002; Hutton et al., 2009; Janssen et al., 2009). Grunebaum does not mention that their findings are actually the opposite of what several rigorous studies have already determined.

Absolute vs relative risk

I’ve also written previously about the dangers of reporting relative risks (“ten times higher!”) without acknowledging that the absolute risk of the complication is actually very, very low. Even if Grunebaum’s study had appropriately excluded outcomes that had nothing to do with place of birth, and even if their source of data was reliably accurate — no one is served by omitting the fact that 5-minute Apgar scores of zero are exceedingly rare.

Some of the raw numbers that Grunebaum reports in the study are so low — less than a dozen events within tens of thousands of births, in some cases — that it is hard to imagine how practitioners could use this information to draw any meaningful conclusions whatsoever about clinical practice.

Even with all of the flaws in this study, the rate of zero Apgars in the “home midwife” category in this study was 1.6/1000. This is a very low number. If these results were valid, it would be these absolute risks that mothers and families should be informed about, and honest discussions should be had regarding why there might be a higher risk in the home setting so that families can make the best decisions for themselves about all of the risks and benefits that come with location of birth.

Transfers not accounted for in “planned” home births

A concern that is often raised by anti-homebirth activists is that births that start out as planned home births but transfer to the hospital in labor are actually counted as hospital statistics in birth certificate data. To be fair, these births likely do have worse outcomes. Although most transfers are for non-urgent reasons such as stalled labor or desire for pain relief (Johnson & Daviss, 2005), some transfers occur because medical assistance is needed and the appropriate place to be is in the hospital.

But let’s look at the real impact of these transports. U.S. data shows that about 10% of planned home births result in transport to the hospital during labor (Johnson & Daviss, 2005). Even if Grunebaum was able to accurately capture planned home births and that number truly was 67,429, we could reasonably assume that about 10% of those babies (6743) were born in the hospital. Those babies account for less than 0.05% of the 14 million babies born in the hospital. Even if every single one of those babies had a 5-minute Apgar score of zero, Grunebaum’s rate of zero Apgars in the hospital would increase from 0.25/1000 to 0.49/1000. In reality, only a very small proportion of home birth transports actually do result in such an adverse outcome, and thus essentially have a negligible effect on hospital outcomes.

On the other hand, even a small percentage of misclassified outcomes in the home birth category have a dramatic impact. Because the number of home births in the U.S. is small, the inclusion of prenatal stillbirths, congenital anomalies and unplanned, unattended home births in the “home midwife” category is likely to have an appreciable effect on the negative outcomes examined here. Furthermore, the 10% of home birthers who transport to the hospital and have positive outcomes there are not appropriately attributed to the planned home birth group either. The truth about the safety of home birth simply cannot be determined in this way.

Reliability of birth certificates

I wrote my initial reaction to Grunebaum et al’s study last week when their press release came out. I expressed concerns about the low reliability and validity of birth certificates for drawing conclusions about rare outcomes. Grunebaum’s own data shows that over 10% of “home midwife” deliveries had no information on the birth certificate about the mother’s parity and had to be excluded from their calculations, while only 0.2-0.5% of hospital or birth center deliveries were missing parity data; this strongly suggests that something is amiss with the “home midwife” data.

Epidemiologists and birth certificate scholars have made their concerns about reliability and validity exceedingly clear in an enormous body of literature over the last few decades, and in fact, expressed these concerns directly to Frank Chervenak (co-author on this study) earlier this year when he presented this very data at the Institute of Medicine’s workshop on Research Issues in the Assessment of Birth Settings (IOM & NRC, 2013, p.143). The fact that these authors were clearly warned about the low quality of their data regarding both low Apgar scores — and especially seizures — but chose to push ahead with publication without addressing them, suggests other motivations.

Summary

Families deserve to have the best possible information with which to make decisions about where to have their babies. Grunebaum and co-authors miss the mark by a wide margin with the methodology and conclusions of this study.

To learn more about existing, well-designed home birth studies, read here. To learn more about the MANA Stats Project, which provides researchers with a dataset of more than 24,000 planned home birth and birth center births, read here. And watch for new research based on the MANA Stats dataset 2004-2009. Two articles are in press and two more are under review in peer-reviewed journals.

References:

Ackermann-Liebrich, U., Voegeli, T., Gunter-Witt, K., Kunz, I., Zullig, M., Schindler, C., Maurer, M. & Zurich Study Team. (1996). Home versus hospital deliveries: follow up study of matched pairs for procedures and outcome. BMJ 313:1313-1318.

Declercq, E., MacDorman, M. F., Menacker, F., & Stotland, N. (2010). Characteristics of planned and unplanned home births in 19 states. Obstetrics & Gynecology 116(1):93-99.

Grunebaum, A., McCullough, L. B., Sapra, K. J., Brent, R. L., Levene, M. I., Arabin, B., & Chervenak, F. A. (2013). Apgar score of 0 at 5 minutes and neonatal seizures or serious neurologic dysfunction in relation to birth setting. Am J Obstet Gynecol, 209:x-ex x-ex.

Hutton, E. K., Reitsma, A. H., & Kaufman, K. (2009). Outcomes associated with planned home and planned hospital births in low-risk women attended by midwives in Ontario, Canada, 2003-2006: a retrospective cohort study. BIRTH 36(3):180-189.

IOM (Institute of Medicine) and NRC (National Research Council). (2013). An Update on Research Issues in the Assessment of Birth Settings: Workshop Summary. Washington, DC: The National Academies Press.

Janssen, P. A., Lee, S. K., Ryan, E. M., Etches, D. J., Farquharson, D. F., Peacock, D., & Klein, M. C. (2002). Outcomes of planned home births versus planned hospital births after regulation of midwifery in British Columbia. CMAJ 166(3):315-323.

Janssen, P. A., Saxell, L., Page, L. A., Klein, M. C., Liston, R. M., & Lee, S. K. (2009). Outcomes of planned home birth with registered midwife versus planned hospital birth with midwife or physician. CMAJ 181(6-7):377-383.

Johnson, K. C. & Daviss, B. A. (2005). Outcomes of planned home births with certified professional midwives: large prospective study in North America. BMJ 330:1416-

Olsen, O. (1997). Meta-analysis of the safety of home birth. BIRTH 24(1):4-13.

About Wendy Gordon

Wendy Gordon, LM, CPM, MPH is a midwife, mother and educator in the Seattle area.  She helped to build a busy, blended homebirth practice of nurse-midwives and direct-entry midwives in Portland, Oregon for eight years before recently transitioning to Seattle.  She is a Coordinating Council member of the Midwives Alliance Division of Research, a board member of the Association of Midwifery Educators, and teaches at the Bastyr University Department of Midwifery.

ACOG, Childbirth Education, Guest Posts, Home Birth, Midwifery, Newborns, Research , , , , , , ,

Assessing Birth Settings to Improve Value and Optimize Outcomes in U.S. Maternity Care

March 12th, 2013 by avatar

by Wendy Gordon, CPM, LM, MPH, MANA Division of Research, Assistant Professor, Bastyr University Dept of Midwifery

Today, occasional contributor, midwife and researcher Wendy Gordon, LM, CPM, MPH, Midwives Alliance Division of Research, shares some insights into some of the fascinating discussions that took place at last week’s Institute of Medicine’s workshop focusing on birth place settings.  From all reports from the many people in attendance, this workshop will hopefully help move the research and discussion on the topic of birth place settings forward and create opportunities for more families to chose to birth where they feel most comfortable and safe. – Sharon Muza, Community Manager, Science & Sensibility

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Hannah Russell-Davis nurses her newborn son
©photo by Michael Davis http://getprivatepractice.com

Last week marked an historic opportunity for maternity care providers to regroup and become inspired to move our professions forward together in all birth settings.  The two-day event, hosted by the prestigious Institute of Medicine (IOM) and sponsored by the W.K. Kellogg Foundation, focused on “Research Issues in the Assessment of Birth Settings” and brought together the greatest minds in research and practice in all three birth settings: home, birth center and hospital.  Issues of tremendous importance to consumers, providers and researchers in the birth community were discussed in a collegial and inspiring manner… marred only by one presentation that stirred a bit of controversy.

Historic Workshop Can Positively Impact Future Research 

Similar to the first IOM conference on this topic over 30 years ago, the intent of last week’s gathering was to discuss the research regarding the effect of place of birth on maternal and infant outcomes. Invited speakers included researchers, public health professionals, midwives, nurses, pediatricians and obstetricians.  In structured mini-sessions, panelists shared their expertise on the following topics:

  • the historical and current picture of who is giving birth in the different settings;
  • definitions of “low-risk” versus “high-risk”;
  •  what the best research says about safety in various settings; 
  • education, regulation and management of different types of providers;
  •  methods of collection and use of data regarding maternity care and birth in various settings; 
  •  cost and value differences between settings and reimbursement issues; and 
  • the rich and varied perspectives of providers in the three childbirth settings.

Members of the audience were just as impressive as the panelists themselves when, at the end of each panel, the microphone was opened and significant content was added through their questions and comments.  

A lot of ground was covered over the course of the two days, and there were several takeaways that had particular impact for the midwifery community. The home birth rate in the U.S. was predicted to continue its rise with the next release of CDC data, reaching about 31,500 births nationwide in 2010. The MANA Stats web-based system was touted by attendees as the best data collection system for home birth outcomes.  Birth certificate data was shown to still have major problems in its ability to accurately capture intended place of birth and other reliability issues, despite improvements in recent years.  A Medicaid study from Washington State demonstrated vast cost savings with midwifery care and birth at home and in birth centers.  The workshop report will have tremendous potential to impact contemporary birth policy and research agendas.

Lack of Consumer Representation and Little Discussion of Health Disparities

There was no consumer representation on workshop panels, nor was there a panel addressing disparities in maternal and infant outcomes, which seems to have been a grave oversight of the organizers.  In the 30 years since the last IOM workshop on birth settings, overall infant mortality has been reduced from 11.5/1000 to 6.7/1000, but the black-white gap has actually increased. In 1982, nearly twice as many babies born to black mothers than white mothers died before their first birthday (19.6 infant deaths per 1000 births vs 10.1/1000; National Center for Health Statistics, 1986). Recent mortality figures show that disparity to be even wider (12.67/1000 vs 5.52/1000; Mathews & MacDorman, 2012).

Hannah Russell-Davis holds her son Jack, moments after his birth at their home in Charlottesville, VA. Jack was Hannah’s third home birth.
© photo by Michael Davis http://getprivatepractice.com

With childbirth in home and birth center settings gaining momentum nationally and at the state level, research to support policy in this direction is more important than ever. The best research has shown for decades, and continues to show, that for women with low-risk pregnancies, birth that is planned to occur in the home and birth center settings with a skilled midwife is no more risky than birth in the hospital and results in far fewer interventions, lower cost and higher satisfaction (Vedam et al, 2012).  Hopefully, the breadth of this research can finally start to expand beyond proving that it is safe.

‘Recrudescence’ Revisited

Despite this body of literature, there are still some physicians who persist in torturing the data in an attempt to frame their personal opinions as “science.”  It was disappointing, although perhaps not surprising, to see Dr. Frank Chervenak use his time on the provider panel to do just that. The American Journal of Obstetrics and Gynecology recently published an article authored by Dr. Chervenak regarding the “recrudescence of homebirth” (Chervenak et al, 2013), and perhaps it was the controversy stirred by that article that prompted the conference organizers to invite him to speak on this panel. The panel members included Dr. Chervenak as a hospital-based provider, Karen Pelote, CNM with the birth center provider perspective, and Brynne Potter, CPM as a homebirth provider.  Both Pelote and Potter appeared to have taken seriously the purpose of their panel representation and showcased the data on our client-centered models of care, with photos and quotes from women regarding the care they received and their experiences in the birth center and home settings.   

In stark contrast, Chervenak used his 12 minutes (out of 10) that were to be devoted to the hospital provider perspective for, instead, a rapid-fire display of “back-of-the-envelope” bar graphs attempting to show home/hospital differences in 5-minute Apgar scores using raw data drawn from birth certificates.  Since it appears that some doctors are having a hard time getting their “research” on this topic published in peer-reviewed journals, they are presenting their data in settings that do not require peer-review, such as last year’s annual conference of the Society of Maternal-Fetal Medicine (the study still hasn’t been published) and this IOM workshop.  Meanwhile, there are several well-designed studies published in peer-reviewed journals that show that there is no difference in 5-minute Apgar scores between home and hospital settings (Hutton et al, 2009; Janssen et al, 2009; van der Kooy et al, 2011).

Apgar Distribution Hospital vs. Home © Dr. Frank Chervenak 2013

That a professional invited to contribute to a high-level workshop about research would present an un-peer-reviewed thesis based on unreliable data, lacking any statistical analysis, is… well, let’s just say “puzzling.”  Exploiting the concept of “relative risk,” Chervenak sliced and diced the data in more ways than were thought possible to suggest that babies born at home were more likely to have a low 5-minute Apgar score than babies born in the hospital.

“Home Births Should Not Happen”

Chervenak’s non-reviewed data did find a higher rate of Apgar scores of “10” in the home setting versus “9” in the hospital setting. His point? Not that, clinically speaking, there is no difference between a score of 9 vs. 10 (they’re both good). Not that babies might possibly be doing better due to normal physiologic labor and undisturbed birth and that we should explore this further. Instead, he suggested – at this historic setting – that midwives lie about Apgar scores because “no one is watching.”  After a day and a half of earnest, interprofessional collegiality, Chervenak wrapped up his extended presentation with his unabashed opinion: “Home births should not happen.”

Epidemiologists in the room were quick to step to the microphone for the open discussion part of the panel, pointing out the many flaws in Chervenak’s presentation.  Marian MacDorman, Ph.D., senior statistician and researcher for the CDC’s National Center for Health Statistics, reminded everyone that birth certificate data is notoriously unreliable for neonatal seizures and low Apgar scores; this has been shown time and again for decades and had indeed been discussed earlier in this very workshop.  More importantly, McDorman stated that data from birth certificates cannot be used to make comparisons between settings or providers.  Her point, which deserves some elaboration here, is that there is a very important distinction between “absolute risk” and “relative risk,” and different types of data are better than others depending on what you are trying to describe. 

“When we limit access to certain birth settings because of risk, are we examining the risks of the alternative?” – Brynne Potter, CPM

Absolute vs. Relative Risk

Let’s say that a person’s odds of getting struck by lightning in a heavily populated city are one in a million, and those same odds in a rural area are five in a million. These odds are called your “absolute risk” of being struck by lightning. Another way to look at this is to say that a person’s odds of being struck by lightning are five times higher in a rural area than in a densely-populated area; this is the “relative risk” of a lightning strike in one area over another.

A common approach of anti-homebirth activists is to use the “relative risk” approach and ignore the absolute risk, because it’s much more dramatic and sensationalistic to suggest that the risk of something is “double!” or “triple!” that of something else, even though the absolute risk of those things are very low and may not even be statistically significantly different from each other.  Of course, any infant or maternal mortality is a tragedy.  But one of the key points raised at the IOM workshop was the idea that, in our efforts to identify “safety” with one indicator (mortality) or “truly low-risk” pregnancies by their absence of a particular factor (breech position, for example), we often fail to quantify all of the impacts of the various settings in ways that are meaningful to the women who experience the outcomes, such as the fact that in many areas, the only option for breech delivery is cesarean or the only way a VBAC can happen is at home, attended or not.  As Brynne Potter asked last week: when we limit access to certain birth settings because of risk, are we examining the risks of the alternative?

To return to the lightning analogy, it would be deeply disingenuous for a person to say that you shouldn’t move to a rural area simply because your risk of being struck by lightning is five times higher, without mentioning that at worst, that risk is five in a million. The ethics of this are further called into question when the person suggesting this is a trusted care provider, and is even worse when that person withholds all information about your option to move to a rural area — disregarding all of your other reasons for wanting to doing so — because they have decided that the risk of being hit by lightning there is too high for you.

Clarifying the Validity of Birth Certificate Data

Dr. MacDorman clarified how to interpret the data for anyone who might have been misled by Dr. Chervenak’s slides. She pointed out that regarding low Apgar scores, “the absolute risk is low; that’s all you can say with vital data.”  It doesn’t happen very often in any setting; most studies on homebirth around the world report the occurrence of low Apgar scores (<7) in the range of 1%, and very low scores (<4) are even rarer.  Studies have shown that the more rare an occurrence is, the less likely it is to be captured accurately on the birth certificate (Northam & Knapp, 2006).

Overall, the Midwives Alliance Division of Research (DOR) and other organizations working to improve maternity care are pleased with the near-consensus viewpoint by the majority of the disciplines represented at this workshop: that normal physiologic birth is best for mother and baby and should be the goal of all settings and practitioners.  We are looking forward to the future research inspired by this event.  We believe that there is potential for there to be more movement in the next 30 years than there was since the last IOM workshop on this topic 30 years ago, particularly because of the availability of high-quality datasets such as MANA Stats (primarily planned home births) and the American Association of Birth Centers’ Uniform Data Set (primarily planned birth center births).  As the stewards of the largest database on midwifery care and outcomes of normal physiologic birth in the home setting, the DOR encourages researchers to apply for the MANA Stats data to conduct this important research (application information at mana.org/DOR). 

References:

Chervenak FA, McCullough LB, Brent RL, Levene MI, Arabin B. 2013. Planned home birth: The professional responsibility response. AJOG 208(1):31-38.

Hutton EK, Reitsma AH, Kaufman K. 2009. Outcomes associated with planned home and planned hospital births in low-risk women attended by midwives in Ontario, Canada, 2003-2006: A retrospective cohort study. BIRTH 36(3):180-189.

Janssen PA, Saxell L, Page LA, Klein MC, Liston RM, Lee SK. 2009. Outcomes of planned home birth with registered midwife versus planned hospital birth with midwife or physician. CMAJ, doi:10.1503/cmaj.081869.

Mathews, TJ & MacDorman, M. 2012. National Vital Statistics Reports: Infant mortality statistics from the 2008 period linked birth/ infant death data set. Available online at http://www.cdc.gov/nchs/data/nvsr/nvsr60/nvsr60_05.pdf

National Center for Health Statistics. 1986. Vital Statistics of the United States, 1982, Vol II: Mortality, Part A. DHHS Pub. No. (PHS) 86-1122. Public Health Service: Washington. U.S. Government Printing Office.

Northam S, Knapp TR. 2006. The reliability and validity of birth certificates. J Obstet Gynecol Neonatal Nurs 35(1):3-12.

van der Kooy J, Poeran J, de Graaf JP, Birnie E, Denktas S, Steegers EAP, Bonsel GJ. 2011. Planned home compared with planned hospital births in the Netherlands: Intrapartum and early neonatal death in low-risk pregnancies. Obstet Gynecol 118:1037-46.

Vedam S, Schummers L, Stoll K, Fulton C. 2012. Home Birth: An Annotated Guide to the Literature.  Available online at http://mana.org/DOR/research-resources/.

About Wendy Gordon

Wendy Gordon, LM, CPM, MPH is a midwife, mother and educator in the Seattle area.  She helped to build a busy, blended homebirth practice of nurse-midwives and direct-entry midwives in Portland, Oregon for eight years before recently transitioning to Seattle.  She is a Coordinating Council member of the Midwives Alliance Division of Research, a board member of the Association of Midwifery Educators, and teaches at the Bastyr University Department of Midwifery.

 

 

Guest Posts, Healthcare Reform, Home Birth, Maternal Mortality, Maternal Mortality Rate, Maternal Quality Improvement, Maternity Care, Midwifery, Newborns, Transforming Maternity Care , , , , , , , , , , , , ,

Obstetricians Claim Homebirth is Unsafe…Again. Where’s The Evidence?

November 29th, 2012 by avatar

by Wendy Gordon, LM, CPM, MPH, Midwives Alliance Division of Research

Today, midwife and researcher, Wendy Gordon, LM, CPM, MPH, Midwives Alliance Division of Research, takes a look at the recent article in the American Journal of Obstetrics and Gynecology that shared the authors’ view of the appropriate professional response from obstetricians when counseling and discussing home birth with patients.  Was this article based on good science?  Accurate and accepted studies? Did the authors selectively choose their sources and ignore other research that may have supported a different viewpoint?  Wendy shares information and research that invites consideration and discussion of the validity of the authors’ opinion. – Sharon Muza, Community Manager.

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flickr.com/photos/bogofoo/4118547231/

Recently, an article in the American Journal of Obstetrics & Gynecology pled with obstetricians to not support planned home birth in any way, and even suggested that those who do “should be subject to peer review and justifiably incur professional liability and sanction from state medical boards” (1).  In their strongly worded opinion, the authors (the first two of whom are, curiously, members of the journal’s Advisory Board, and four of whom are also board members of the International Society of Fetus as a Patient) make their case that physicians should provide evidence-based information to women that planned home birth is not safe, that reports of patient satisfaction are overrated, that it’s actually not cost-effective, and that a pregnant woman has a moral duty to her fetus to give up her autonomy to her doctor’s judgment on this issue.  Let’s take a look at the basis for these recommendations.

Although there are many high-quality studies of home birth on which Chervenak et al. could have based their opinions, they led with the ACOG statement (2) that rests on the findings of the Wax et al. meta-analysis (3), which relied heavily on a study that included unplanned home births in its findings of neonatal mortality rates (4).  Many strong critiques of the Wax analysis have been published (5-11), including an unbiased look from someone who has no stake in the home birth debate.  The authors cited several more poor-quality studies, as well as 52 citations of commentaries, opinions and anecdotes (some even pulled from the popular media) to build their “evidence” basis. They conveniently ignored the large and growing body of literature that continues to show that planned home birth with qualified and experienced midwives holds no greater risk of perinatal mortality than birth in the hospital, and in fact results in far fewer interventions and lower risk of maternal and perinatal morbidity.

Here are some of the high-quality studies that Chervenak et al. did not cite in developing their opinion of the “professional responsibility response”:

  • two systematic reviews (12-13) and a meta-analysis (14) of home and birth center safety studies that all show that there is no greater perinatal risk for planned, attended home births than for hospital births, and significantly fewer interventions;
  • the only large-scale, high-quality study of Certified Professional Midwives (CPMs) in the U.S. that described intrapartum and neonatal death rates as similar to other studies of low-risk home and hospital births (15);
  •  other high-quality U.S. studies that show no difference in perinatal mortality between planned home and hospital births (16-18);
  • several high-quality Canadian studies confirming no difference in the rates of perinatal death between planned home and hospital birth with much lower rates of both interventions and adverse outcomes (19-21);
  •  a huge Dutch study of over half a million births that shows no difference in perinatal mortality rates or NICU admissions between planned home and hospital births (22);
  • another Dutch study that shows no difference in perinatal mortality and lower risk of interventions and other adverse outcomes, particularly for multips (23);
  • large, high-quality U.K. studies that show no difference in perinatal mortality rates and lower risk of both interventions and adverse outcomes (24-25); and
  • a German study that shows no difference in rates of perinatal mortality and lower risk of interventions and adverse outcomes (26).

The authors then go on to discount the evidence of higher satisfaction among women choosing to deliver at home, as well as the cost-effectiveness of doing so, while presenting absolutely no evidence to the contrary.  The authors reference a study in the Netherlands where the transport rate from home to hospital is over twice that in the U.S. (and where Chervenak et al. took great liberties in interpreting the results on patient satisfaction) and a U.K. study where the costs of home and hospital birth are virtually equivalent.  While consistent, this approach to selectively reviewing the evidence and generalizing the findings to the U.S. maternity care system is disingenuous and deliberately misleading to American obstetricians and their patients.  A Washington State study of Medicaid patients planning a home birth with Licensed Midwives showed a savings of nearly $3 million, including the increased cost of those who transferred care and/or site of delivery (27).  This analysis did not attempt to account for the vast cost reductions of potentially avoided interventions, including cesareans and their complications, which would make the case for the cost-effectiveness of midwifery-led care in Washington State even stronger.  It is puzzling that Chervenak et al. did not cite this study, which is recent, took place in the U.S., was conducted by unbiased health-economics consultants, and directly addresses one of their four concerns.

The authors’ main argument against the proven cost-effectiveness of planned home birth is that “the lifetime costs of supporting the neurologically disabled children who will result from planned home birth” have not been factored in, nor have the supposedly increased rates of death.  If one accepts the conclusions of the enormous body of literature that finds no difference in perinatal mortality rates or other adverse outcomes between planned, midwife-attended home births and hospital births, then the pursuit of this line of reasoning is a non-starter.

The U.S. continues to lag behind many other high- and low-resource countries in accepting the evidence of the vast benefits of midwifery care.  The U.K.’s National Health Service has encouraged women to plan home births with midwives for several years; the Netherlands has always acknowledged midwives as the primary care provider in the childbearing year; New Zealand’s system similarly places midwives at the forefront of maternity and newborn care; Japan has a long tradition of midwifery-led care.  Most recently, British Columbia Health Minister MacDiarmid, accepting the evidence of safety, patient satisfaction and cost-effectiveness, has announced government support for women with low-risk pregnancies to plan a home birth, including support for physicians to become appropriately trained to attend home births (28).  But the medical associations of the U.S. continue to erect barriers to the type of interprofessional collaboration that has resulted in the excellent outcomes of these other countries.  The Chervenak et al. article is clearly intended to be yet another of those barriers.

In the centerpiece of the AJOG article, Chervenak cites himself an astounding 15 times in justifying why the rights of a pregnant woman to make autonomous decisions for herself and her baby should be relegated to her doctor’s judgment of what’s right for the “fetus as a patient,” grounded firmly, of course, in the aforementioned “evidence.”  In an astonishing disregard for shared decision-making and informed choice, Chervenak et al. state that “in a professional relationship, the physician’s integrity justifiably limits the woman’s rights by limiting the scope of clinically reasonable alternatives.”  The authors’ repeated and unusual use of the word “recrudescence” when referring to home birth, which reveals their perception of the choice as a disease or disorder, and their stubborn contempt for high-quality evidence if it disproves their opinion, exposes their intent and certainly calls into question their “integrity.”

“Professional responsibility” demands that we dare to examine the evidence that does not agree with our personal beliefs.  It requires that we allow the volumes of high-quality evidence to seep into our analysis of reality and into our presentation of true informed choice to our patients.  “Professional responsibility” demands that we examine and disclose our own personal, religious or anecdotal beliefs that may bias our interpretation and presentation of the research.  And it requires that we refuse to cloak those personal beliefs as “evidence” and “integrity” and by so doing avoid an abuse of power in relationship with our patients.

References

1. Chervenak F. A., McCullough L. B., Brent R. L., Levene M. I., & Arabin B. (2012) Planned home birth: the professional responsibility response. Am J Obstet Gynecol, Nov 13. doi:10.1016/j.ajog.2012.10.002. [Epub ahead of print].

2. American College of Obstetricians and Gynecologists. (2011). Committee Opinion no. 476. Committee on Obstetric Practice. Planned home birth. Obstet Gynecol, 117(2, part 1), 425-8.

3. Wax J. R., Lucas F. L., Lamont M., Pinette M. G., Cartin A., & Blackstone J. (2010).  Maternal and newborn outcomes in planned home birth vs. planned hospital births: a metaanalysis. Am J Obstet Gynecol, 203(3):243.e1–243.e8. doi:10.1016/j.ajog.2010.05.028

4. Pang J. W., Heffelfinger J. D., Huang G. J., Benedetti T. J., & Weiss N. S. (2002). Outcomes of planned home births in Washington state: 1989-1996. Obstet Gynecol, 100(2):253-9. http://dx.doi.org/10.1016/S0029-7844(02)02074-4

5. Carl M. A., Janssen P. A., Vedam S., Hutton E. K., & de Jonge A. (2011). Planned home vs hospital birth: A meta-analysis gone wrong. Medscape Ob/Gyn & Wom Health. Retrieved from http://www2.cfpc.ca/local/user/files/%7B1E683014-14EB-489F-99CE-B5A2185A6FC5%7D/Medscape%20%20Wax%20Critique%20-%20Michal,%20Janssen,%20Vedam,%20Hutton,%20de%20Jonge.pdf

6. Gyte G., Newburn M., & Macfarlane A. (2010). Critique of a meta-analysis by Wax and colleagues which has claimed that there is a three-times greater risk of neonatal death among babies without congenital anomalies planned to be born at home. National Childbirth Trust. Retrieved from http://www.scribd.com/doc/34065092/Critique-of-a-metaanalysis-by-Wax

7. Keirse M. J. (2010). Home birth: Gone away, gone astray, and here to stay. Birth, 37(4):341-46.

8. Hayden E. C. (2011). Home birth study investigated. Nature [Epub]. doi:10.1038/news.2011.162.

9. American College of Nurse Midwives. (2010). ACNM expresses concerns regarding recent AJOG publication on home birth. [Epub]. Retrieved from http://www.midwife.org/documents/ACNMstatementonAJOG2010.pdf.

10. Romano A. (2010). Meta-analysis: the wrong tool (wielded improperly). Retrieved from http://www.scienceandsensibility.org/?p=1349.

11. Dekker R. & Lee K. S. (2012). The Wax home birth meta-analysis: an outsider’s critique. Retrieved from http://www.scienceandsensibility.org/?p=5628.

12. Olsen O. & Clausen J. A. (2012). Planned hospital birth versus planned home birth. Cochrane Database of Systematic Reviews, Issue 9. Art. No.: CD000352. doi: 10.1002/14651858.CD000352.pub2.

13. Leslie M. S. & Romano A. (2007). Appendix: Birth can safely take place at home and in birthing centers. J Perinat Educ, 16(Suppl 1):81S-88S. doi:10.1624/105812407X173236

14. Olsen O. (1997). Meta-analysis of the safety of home birth. Birth, 24(1):4-13; discussion 14-6.

15. Johnson K. C. & Daviss B-A. (2005). Outcomes of planned home births with certified professional midwives: large prospective study in North America. BMJ, 330:1416. doi: http://dx.doi.org/10.1136/bmj.330.7505.1416

16. Cawthon L. (1996). Planned home births: outcomes among Medicaid women in Washington State. Olympia,WA: Washington Department of Social and Health Services. Retrieved from http://www.dshs.wa.gov/pdf/ms/rda/research/7/93.pdf.

17. Murphy P. A. & Fullerton J. (1998). Outcomes of intended home births in nurse-midwifery practice: a prospective descriptive study. Obstet Gynecol, 92(3):461-70.

18. Anderson R. E. & Murphy P.A. (1995). Outcomes of 11,788 planned home births attended by certified nurse-midwives: A retrospective descriptive study. J Nurse Midwifery, 40(6):483-92.

19. Janssen P. A., Saxell L., Page L. A., Klein M. C., Liston R. M. & Lee S.K. (2009). Outcomes of planned home births with registered midwife versus planned hospital birth with midwife or physician. CMAJ, 181(6):377-83.

20. Hutton E. K., Reitsma A.H. & Kaufman K. (2009). Outcomes associated with planned home and planned hospital births in low-risk women attended by midwives in Ontario, Canada, 2003-2006: A retrospective cohort study. Birth, 36(3):180-89.

21. Janssen P. A., Lee S. K., Ryan E. M., Etches D. J., Farquharson D. F., Peacock D. & Klein M. C. (2002). Outcomes of planned home births versus planned hospital births after regulation of midwifery in British Columbia. CMAJ, 166(3):315-23.

22. de Jonge A., van der Goes B. Y., Ravelli A. C., Amelink-Verburg M. P., Mol B. W., Nijhuis J. G., Bennebroek Gravenhorst J. & Buitendijk S. E. (2009). Perinatal mortality and morbidity in a nationwide cohort of 529,688 low-risk planned home and hospital births. BJOG, 116(9):1177-84. DOI: 10.1111/j.1471-0528.2009.02175.x.

23. Wiegers T. A., Keirse M. J., van der Zee J. & Berghs G. A. (1996). Outcome of planned home and planned hospital births in low risk pregnancies: prospective study in midwifery practices in the Netherlands. BMJ, 313(7068):1309-13

24. Chamberlain G., Wraight A. & Crowley P. (eds.). (1997). Home births – The report of the 1994 confidential enquiry by the National Birthday Trust Fund. Cranforth, UK: Parthenon Publishing.

25. Northern Region Perinatal Mortality Survey Coordinating Group. (1996). Collaborative survey of perinatal loss in planned and unplanned home births. BMJ, 313(7068):1306-09. doi: http://dx.doi.org/10.1136/bmj.313.7068.1306.

26. Ackermann-Liebrich U., Voegeli T., Gunter-Witt K., Kunz I., Zullig M., Schindler C., Maurer M. & Zurich Study Team. (1996). Home versus hospital deliveries: follow up study of matched pairs for procedures and outcome. BMJ, 313(7068):1313-18. doi: http://dx.doi.org/10.1136/bmj.313.7068.1313.

27. Health Management Associates. (2007). Midwifery licensure and discipline program in Washington State: economic costs and benefits. Retrieved from http://www.washingtonmidwives.org/documents/Midwifery_Cost_Study_10-31-07.pdf.

28. Dedyna K. (2012, Nov 3). B.C. minister among first to support home births. Times Colonist. Retrieved from http://www.canada.com/minister+among+first+support+home+births/7494815/story.html.

About Wendy Gordon

Wendy Gordon, LM, CPM, MPH is a midwife, mother and educator in the Seattle area.  She helped to build a busy, blended homebirth practice of nurse-midwives and direct-entry midwives in Portland, Oregon for eight years before recently transitioning to Seattle.  She is a Coordinating Council member of the Midwives Alliance Division of Research, a board member of the Association of Midwifery Educators, and teaches at the Bastyr University Department of Midwifery.

 

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