An article in The New York Times Opinion Pages – Room for Debate was released on February 24th, 2015. As customary in this style of article, the NYT asks a variety of experts to provide essays on the topic at hand, in this case, the safety of home birth. Henci Goer, author and international speaker on maternity care, and an occasional contributor to our blog, takes a look at the facts on home birth and evaluates how they line up with some of the essay statements. Read Henci’s analysis below. – Sharon Muza, Science & Sensibility Community Manager
As one would predict, three of the four obstetricians participating in the NY Times debate “Is Home Birth Ever a Safe Choice?“assert that home birth is unacceptably risky. Equally predictably, the evidentiary support for their position is less than compelling.
John Jennings, MD president of the American Congress of Obstetricians & Gynecologists, in his response- “Emergency Care Can Be Too Urgently Needed,” cites a 2010 meta-analysis by Wax and colleagues that has been thoroughly debunked. Here is but one of the many commentaries, Meta-Analysis: The Wrong Tool Wielded Improperly, pointing out its weaknesses. In a nutshell, the meta-analysis includes studies in its newborn mortality calculation that were not confined to low-risk women having planned home births with a qualified home birth attendant while omitting a well-conducted Dutch home birth study that dwarfed the others in size and reported equivalent newborn death rates in low-risk women beginning labor at home and similar women laboring in the hospital (de Jonge 2009).
The other naysayers, Grunebaum and Chervenak, in their response – “Home Birth Is Not Safe“, source their support to an earlier NY Times blog post that, in turn, cites a study conducted by the two commentators (and others) (Grunebaum 2014). Their study uses U.S. birth certificate data from 2006 to 2009 to compare newborn mortality (day 1 to day 28) rates at home births attended by a midwife, regardless of qualifications, with births attended by a hospital-based midwife, who almost certainly would be a certified nurse midwife (CNM) in babies free of congenital anomalies, weighing 2500 g or more, and who had reached 37 weeks gestation. The newborn mortality rate with home birth midwives was 126 per 10,000 versus 32 per 10,000 among the hospital midwives, nearly a 4-fold difference. However, as an American College of Nurse-Midwives commentary on the abstract for the Society for Maternal-Fetal Medicine presentation that preceded the study’s publication observed, vital statistics data aren’t reliably accurate, don’t permit confident determination of intended place of birth, and don’t follow transfers of care during labor.
As it happens, we have a study that is accurate and allows us to do both those things. The Midwives Alliance of North America study reports on almost 17,000 planned home births taking place between 2004 and 2009 (Cheyney 2014b), and therefore overlapping Grunebaum and Chervenak’s analysis, in which all but 1000 births (6%) were attended by certified or licensed home birth midwives. According to the MANA stats, the newborn death rate in women who had never had a cesarean and who were carrying one, head-down baby, free of lethal congenital anomalies was 53 per 10,000, NOT 126 per 10,000. This is less than half the rate in the Grunebaum and Chervenak analysis. (As a side note, let me forestall a critique of the MANA study, which is that midwives simply don’t submit births with bad outcomes to the MANA database. In point of fact, midwives register women in the database in pregnancy [Cheyney 2014a], before, obviously, labor outcome could be known. Once enrolled, data are logged throughout pregnancy, labor and birth, and the postpartum, so once in the system, women can’t fall off the radar screen.)
We’re not done. Grunebaum and Chervenak’s analysis suffers from another glaring flaw as well. Using hospital based midwives as the comparison group would seem to make sense at first glance, but unlike the MANA stats, which recorded outcomes regardless of where women ultimately gave birth or who attended them, hospital-based midwives would transfer care to an obstetrician when complications arose. This would remove labors at higher risk of newborn death from their statistics because the obstetrician would be listed on the birth certificate as the attendant, not the midwife. For this reason, the hospital midwife rate of 32 per 10,000 is almost certainly artificially low. So Grunebaum and Chervenak’s difference of 94 per 10,000 has become 21 per 10,000 at most and probably much less than that, a difference that I’d be willing to bet isn’t statistically significant, meaning unlikely to be due to chance. On the other hand, studies consistently find that, even attended by midwives, several more low-risk women per 100 will end up with cesarean surgery—more if they’re first-time mothers—then compared with women planning home births (Romano, 2012).
Hopefully, I’ve helped to provide a defense for those who may find themselves under attack as a result of the NY Times article. I’m not sanguine, though. As can be seen by Jennings, Grunebaum, and Chervenak, people against home birth often fall into the category of “My mind is made up; don’t confuse me with the facts.”
photo source: creative commons licensed (BY-NC-SA) flickr photo by HoboMama: http://flickr.com/photos/44068064@N04/8586579077
Cheyney, M., Bovbjerg, M., Everson, C., Gordon, W., Hannibal, D., & Vedam, S. (2014). Development and validation of a national data registry for midwife-led births: the Midwives Alliance of North America Statistics Project 2.0 dataset. J Midwifery Womens Health, 59(1), 8-16. doi: 10.1111/jmwh.12165 http://www.ncbi.nlm.nih.gov/pubmed/24479670
Cheyney, M., Bovbjerg, M., Everson, C., Gordon, W., Hannibal, D., & Vedam, S. (2014b). Outcomes of care for 16,924 planned home births in the United States: the midwives alliance of north america statistics project, 2004 to 2009. J Midwifery Womens Health, 59(1), 17-27. doi: 10.1111/jmwh.12172 http://www.ncbi.nlm.nih.gov/pubmed/24479690
de Jonge, A., van der Goes, B. Y., Ravelli, A. C., Amelink-Verburg, M. P., Mol, B. W., Nijhuis, J. G., . . . 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), 1177-1184. http://www.ncbi.nlm.nih.gov/pubmed?term=1177%5Bpage%5D+AND+2009%5Bpdat%5D+AND+de+jonge%5Bauthor%5D&cmd=detailssearch
Grunebaum, A., McCullough, L. B., Sapra, K. J., Brent, R. L., Levene, M. I., Arabin, B., & Chervenak, F. A. (2014). Early and total neonatal mortality in relation to birth setting in the United States, 2006-2009. Am J Obstet Gynecol, 211(4), 390 e391-397. doi: 10.1016/j.ajog.2014.03.047 http://www.ajog.org/article/S0002-9378(14)00275-0/abstract
Romano, A. (2012). The place of birth: home births. In Goer H. & Romano A. (Eds.), Optimal Care in Childbirth: The Case for a Physiologic Approach. Seattle, WA: Classic Day Publishing.
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.e241-e248. http://www.ajog.org/article/S0002-9378%2810%2900671-X/abstract
About Henci Goer
Henci Goer, award-winning medical writer and internationally known speaker, is the author of The Thinking Woman’s Guide to a Better Birth and Optimal Care in Childbirth: The Case for a Physiologic Approach, She is the winner of the American College of Nurse-Midwives “Best Book of the Year” award. An independent scholar, she is an acknowledged expert on evidence-based maternity care.
Babies, Evidence Based Medicine, Guest Posts, Home Birth, Maternal Quality Improvement, Maternity Care, Midwifery