Flaws In Recent Home Birth Research May Mislead Parents, Providers

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

_______________________________

© 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.

61 Comments

Flaws In Recent Home Birth Research May Mislead Parents, Providers

September 26, 2013 03:00 PM by Tina Tsiakalis
Excellent piece, Wendy. Thank you!

Flaws In Recent Home Birth Research May Mislead Parents, Providers

September 26, 2013 03:00 PM by MomOfMore
Am I the only person who doesn't think that 1.6/1000 is not that low at all? That's 1 in 625. I don't think that 1 in 625 home birth moms having a 5 minute Apgar of 0 is low at all (note: this says absolutely nothing about 5 minute Apgars of 1, 1 minute Apgars of 0, etc). This metric is really upsetting to see, but it doesn't create a full picture of what the actual risk of neurological injury is going to be with a planned home birth. I would like to understand better why anyone would argue that "home, midwife" on birth certificate data would be likely to include unplanned, unattended home birth as well. In order for this to be true, you'd have a situation where the mother would be having to assign Apgar scores on birth certificate data, and I find that to be not a terribly plausible scenario. If anything, this should skew the other direction in states with questionable legality where a midwife may be constrained by hostile community standards and may not transfer soon enough and have a birth that was midwife attended be marked as unassisted. How does Ms. Gordon account for mismarked birth certificates in states where home birth midwives are underground? I've had three home births. I am deeply unsettled by this research, including that it seems Ms. Gordon is saying that a 1 in 625 risk of a 5 minute Apgar of 0 is a tolerable risk. It never would have been tolerable to me, and I wonder how many other mothers who only felt comfortable with home birth under the conviction that it was at least as safe as hospital birth would feel the same way. A 10 times different magnitude of risk isn't statistical static. It's just not. I'd buy that 2-3 times could be miscounting and margin of error. Not 10 times, especially not when I'm finding the argument that this under-represents planned home birth by not being able to account for transfers of babies who are entrapped breech births, etc. The one thing that I see that is a serious potential flaw in the Zero Apgar study is that it does not account for breech. I would be very interested to see how many of those 5 minute Apgars of 0 are breech presentations. Two of my three home births were in the study period described above. I look forward to reading the results of those studies, particularly as pertains to mortality stats.

Flaws In Recent Home Birth Research May Mislead Parents, Providers

September 26, 2013 03:00 PM by Wendy Gordon, CPM, LM, MPH
@MomOfMore This is not a discussion about what is "tolerable" -- that is a decision that each mother and family should make for themselves within the context of their own priorities, but it should be made with full information. This study has so many flaws that we can't say with any degree of certainty that 1.6/1000 is an accurate statistic on which to base decisions about location of birth. We are taking a leap of faith to pretend that the study was methodologically sound in order to accept a rate of 1.6/1000 for the purposes of this discussion, and if it were real, this would be considered a rare event, on a par with the low end of the incidence of cord prolapse. What families do with this information -- if it were accurate -- is an important decision that should be made with the most rigorous unbiased information possible. Grunebaum et al fell far short of the bar on rigor with this study. We don't have any research on how birth certificates are completed in states where home birth midwives are underground. Nor do we have good research on how the birth certificates are completed when home births are unassisted and/or unplanned. Declercq et al's 2010 study (cited above) indicated that 5% of home births were "attended" by physicians. As a midwife practicing in a relatively homebirth-friendly state, I find it tremendously hard to believe that 5% of U.S. home births are actually attended by physicians. There are probably a whole lot of issues with the reliability of birth certificates (among other things) when midwives have to practice underground, which lends further to the premise that birth certificates are a very poor choice of data source when looking at rare outcomes in less than 1% of the population.

Flaws In Recent Home Birth Research May Mislead Parents, Providers

September 27, 2013 03:00 PM by Amy V. Haas
The bottom line is that this study is not reliable. Until and unless it is done in a proper manner, then the previously well constructed studies still stand. planned Home birth, for a low risk Mom, with a Midwife (or some other licensed care provider) in attendance, results in better outcomes than hospital birth.

Flaws In Recent Home Birth Research May Mislead Parents, Providers

September 27, 2013 03:00 PM by Monica
@Amy V. Haas And how would we know that home birth in the US with a low risk mom and a US trained midwife is really safe when MANA still won't release the death rate in homebirth? Kind of hard to make a conclusive study without that information. So I suppose we have to do with what we have and since we don't have those vital numbers from MANA. But you're right, this study is flawed. Not because of the reason stated here, but because one has to call into question the code of ethics by which unmonitored midwives are following when they fill out this information about newborns. That actually leads me to believe the risk is most likely even greater than is being presented. But again, when a group of "licensed" care providers are stonewalling one really must begin to question all of the data.

Flaws In Recent Home Birth Research May Mislead Parents, Providers

September 27, 2013 03:00 PM by Wendy Gordon, LM, CPM, MPH
@Monica, as stated above, two articles are in press regarding methods and outcomes from the 2004-09 MANA Stats registry and two more are under review.

Flaws In Recent Home Birth Research May Mislead Parents, Providers

September 27, 2013 03:00 PM by Anon
I find MANA to be quite deceiving in their honesty. I can find data about MANAstats results about Homebirth deliveries with regards to 1) low 5 minute APGARS: 1.37% 2) delivery before 37 weeks: 1.4% 3) spontaneous vaginal delivery: 91.6% 4) forceps 0.2% 5) cesarean: 5.03% 6) low birth weight <2500: 0.93% 7) intrapartum transfer: 10.6% 8) neonatal transfer: 0.8% 9) post partum transfer: 1.76%, but nothing about what everyone wants to know, the perinatal death stats. Anyone can figure out why these are not available, and I just can't wait to decipher through the misdirection of lies that will be spun to try and lessen the significance of the results. If I worked for MANA and had favorable results, I would be posting them at the top of that list that is already available.

Flaws In Recent Home Birth Research May Mislead Parents, Providers

September 27, 2013 03:00 PM by Mari Patkelly
Thanks Sense and Sensibility for hosting Wendy as she educates us all in regards to ethical research practices and the state of research on home birth as it currently exists. As more and more reliable information is available more understanding will prevail.

Flaws In Recent Home Birth Research May Mislead Parents, Providers

September 27, 2013 03:00 PM by Anon
I see that this study that Wendy finds to be flawed also correlates with Judith Rooks research into the Oregon Homebirth statistics. Can Wendy please comment on Judith Rooks findings? https://olis.leg.state.or.us/liz/2013R1/Downloads/CommitteeMeetingDocument/8585

Flaws In Recent Home Birth Research May Mislead Parents, Providers

September 27, 2013 03:00 PM by another anon
I am also interested in Ms. Gordon's take on Judith Rooks' findings. Considering that they are consistent with the Grunebaum study I find the results incredibly concerning. It also seems disingenuous to try to blame some of the differences in rate on the possibility of such things as congenital abnormalities. If the standard of care for home births is so different from hospital births that such things are not captured as prenatal stillbirths and congenital abnormalities, then that is very very concerning about the level of care available to women choosing home birth. Finally, a thought about absolute versus relative risk. Every time I get in a car or ride a bicycle I face a low absolute risk of injury as a result of a collision. However, there is a huge difference in relative risk between wearing a seat belt or helmet or choosing to forgo those safety measures. Because the consequences of a collision are so severe, I choose to wear my seat belt every time I get in the car and a helmet every time I ride a bike. Informed decision making requires understanding of both the absolute and relative risks involved in a decision of where to give birth.

Flaws In Recent Home Birth Research May Mislead Parents, Providers

September 27, 2013 03:00 PM by Liz
"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." Wouldn't the thing that's "amiss" be the fact that midwives are apparently really bad at performing the very basic task of keeping complete and accurate records? And this is supposed to REASSURE us about homebirth? Holy moly, that's bad.

Flaws In Recent Home Birth Research May Mislead Parents, Providers

September 27, 2013 03:00 PM by Monica
Wendy Gordon, LM, CPM, MPH : @Monica, as stated above, two articles are in press regarding methods and outcomes from the 2004-09 MANA Stats registry and two more are under review. Oh yeah? Are they available to the public? How do we get our hands on this information. You're talking about flaws and misleading people, but I have yet to see MANA share death rates. Wanna do that now? I suppose I won't be holding my breath on that.

Flaws In Recent Home Birth Research May Mislead Parents, Providers

September 28, 2013 03:00 PM by Siri Dennis
@another anon Exactly! Every mother whose baby is lost due to lack of skilled attendants and/or proper resuscitative facilities will find that her baby is absolutely dead, not relatively. And some of the babies with Apgars of 1, 2, 3, 4 etc at five minutes will have disabilities that mean they will never lead independent lives. An Apgar of 0 at 5 is by no means the only possible bad outcome.

Flaws In Recent Home Birth Research May Mislead Parents, Providers

September 28, 2013 03:00 PM by Siri Dennis
Yes, as more information is available, understanding WILL prevail, and when at long last MANA publishes its death rates (ie when they run out of excuses), women and families will understand how big a risk they are really taking...@Mari Patkelly

Flaws In Recent Home Birth Research May Mislead Parents, Providers

September 28, 2013 03:00 PM by Another Liz
I have criticisms of this latest research article on OOH birth, but that does not erase my criticism of MANA?s blind and blanket support of any and all OOH midwifery practices in the name of ?informed choice?. I have been a MANA member for over 10 years. I have been a homebirth advocate, midwifery advocate, and a home birth parent. I love and support midwifery and OOH birth. I am pro-choice and pro-natural childbirth. I hold immense disdain for those who cry ?dead babies!? as a way to limit women?s reproductive choices. But I find myself uttering ?what about the babies who needlessly die at OOH births?? because there are too many ?choices? in childbirth that are defended by professional organizations such as MANA. One baby who dies due to ideological premise of ?informed choice? in childbirth is one too many. And many, many more babies have died under the care of Certified Professional Midwives willfully attending breech, twin and VBAC labors in the out-of-hospital setting. How is this defensible, MANA? What is your angle? It is vile and reprehensible. It must stop. Enough. Enough of celebrating midwifery for high-risk mothers! Enough of this! It is time to stop defending the reckless practices of ?supporting a woman?s informed choice to birth OOH under risky circumstances? (sometimes this is not support, but outright coercion), it is time to re-group, it is time to re-think what MANA supports in the practice of OOH midwifery, and it is time to take a stand of what truly constitutes the safest OOH birth practices.

Flaws In Recent Home Birth Research May Mislead Parents, Providers

September 28, 2013 03:00 PM by L Chambers
I have a few questions. In the case of over 10% of home midwife deliveries having no information about mother's parity, I wonder if it is because baby was transferred and the hospital did the birth certificate and didn't know the information- they also would not have known the apgar scores. I have done a neonatal transfer and the hospital insisted on doing the birth certificate- but they never asked for information so I assume that they left things blank or zeroes. Something to think about. In thinking through this (as a midwife) I see how the data used is not adequate. It leaves too many questions: if birth certificates were used and not death certificates what does that mean, why not compare 1 minute apgars to 5, and of course there is the intended place of delivery and how the paperwork is actually done. I know from experience that is not a perfect system.

Flaws In Recent Home Birth Research May Mislead Parents, Providers

September 28, 2013 03:00 PM by Sarah Taylor
I am wondering if this might be an indication for increased training on Apgar scores. I reviewed charts where midwives wrote 0 Apagar for babies, who upon questioning, did not have a zero Apgar. It looked like some were giving a zero for all babies that needed help to breathe. This was true of experienced and student midwives. One midwife said she was too busy looking at her watch and counting breaths and heartbeats to do an accurate Apgar. Too often they are written in retrospect, from memory. This seems true in any setting. Apgar scores require skill in observation. It also has to be clear who is establishing this score, what their experience is and how they communicate this score so it can be recorded. It may be possible that apprentice midwives are establishing this score without enough training or experience. The study leaves many questions but may indicate a nudge to review everyone's Apgar scoring skill and protocols just in case that was part of the problem. If Apgars are to be accurate for such a study, it seems it must be the score that the baby has on its own without life support or an indication on the birth certificate that it is an assisted score. Of course what is important is the indicators and actions related to a possible or predicted low score.

Flaws In Recent Home Birth Research May Mislead Parents, Providers

September 28, 2013 03:00 PM by Liz
L chambers, there is no way the lack of information on birth certificates does anything but reflect badly on midwives. First of all, it is completely implausible that a hospital would just be missing that information, regardless of how the mother comes in. That is basic information they need to make care decisions and they are going to ask and put it in the chart. But let's say, for the sake of information, they these ARE transfers and the hospitals ARE missing that info. That is still the midwife's fault. Part of a being a responsible midwife is accompanying the mother to the hospital and providing all the relevant information to the doctors there so that can provide correct treatment immediately. The midwife should have basic information like parity in file, ready to hand over. The MOST favorable conclusion is that midwives are sloppy. A worse possibility is that don't fill in parity because they never bothered to find out. Worst is that they know parity and are intentionally hiding information because they know that serving first-time mothers, or multiple-VBAC homebirths is something that violates standards of care, but they want to do it anyway.

Flaws In Recent Home Birth Research May Mislead Parents, Providers

September 28, 2013 03:00 PM by Darla Torrez, LM CPM
But what about the other birth data? And who is filing these certificates? Who is assessing these five minute Apgars of O, and what are the 10 minute scores? When a 5 min Apgar of less than 7 is recorded on my State's electronic birth cert filing program, it automatically requires a 10 minute score. This score would only be absent on a legal certification in my state if the infant never had another Apgar assessment, in which case s/he would be dead, and a death certificate would be filed instead. There are also sections asking if the infant was transferred within 24 hours and if the infant died after a live birth. To the extent that it is possible to infer anything from birth certificate data, a well done study might have included this information in their analysis, as well as looking at reported abnormal conditions of the newborn, congenital anomalies, characteristics of labor, and maternal morbidity, all of which can be found right there on the same certificate. That the researchers had access to this data is proven by the inclusion of the relative incidence of "seizures or serious neurological dysfunction" in their data set. What is interesting to me is that none of the other "abnormal conditions of the newborn" included on all US birth certificates are even discussed in this study. Are we to assume that these seizures and neurological dysfunctions happened in a vacuum, unrelated to assisted ventilation, admission to NICU, or suspected neonatal infection? Who made these assessments of neurological dysfunction, anyway? And are these a subset of the neonates with the dubious Apgar scores, an entirely different subset with their own outcomes, or what? I just don't understand why Chervenak, et al chose to focus particularly on seizures and 5 minute Apgar scores, and how they believe this data,extracted willy-nilly from a larger set of statistical information, can really be useful as "prognostic data for future outcomes." I do understand that the researchers in this case have an obvious bias, and are merely furthering the stated agenda of ACOG to aggressively hold their ground against the "recrudescence" of home birth by cherry picking the data, but all it really proves is that birth certificate statistics are an easily exploited but ultimately unreliable source for that data, as was already proven by the notorious and embarrassingly flawed Pang study, which no one (except midwives,haha) wants to talk about anymore. Come on ACOG, you can do better than that.

Flaws In Recent Home Birth Research May Mislead Parents, Providers

September 28, 2013 03:00 PM by Darla Torrez, LM CPM
@Liz Hospitals make egregious errors on birth certificates all the time. The birth cert is usually prepared by a ward clerk who has nothing to do with the birth itself, and signed on the fly by the attending physician as they go out the door. That is why they send the parents home with an informational copy of the Clerk & Recorder part, where the name and parents are listed, so they can make changes when they see the hospital has made a mistake. Unfortunately, the statistical, clinical part of the cert is unavailable for review by parents, even if they did know enough to recognize a mistake when they saw one. And you bet they make a lot of mistakes on those. Are you saying that midwives are never allowed to make clerical errors? Even a few such errors might have a big impact on such a small data set as out of hospital births. And although it has not happened to me in my state, I know that hospitals in neighboring areas do occasionally file birth certificates on neonates transferred into their care. If there is any fault to be laid on the midwife in these cases it is that they allow themselves to get pushed around by hospital staff. The current state of dysfunction and often outright hostility that characterizes so many transfers does not help matters. I have had whole charts lost by hospital staff who took them "just to make copies" and somehow permanently misplaced them, and I have had hospital staff refuse to even look at my charts, since being a state licensed CPM means I am uncredentialed, unskilled, and obviously illiterate. And since when are all VBACS and especially all first timers considered high risk? Good Lord, the first timers are the ones most at risk of bad outcomes in a hospital setting! Are we supposed to force women to survive the gauntlet of hospital birth with an intact uterus before they deserve to have a home birth? You do realize that cuts out at least 32%of birthing women, right? I can see being afraid of VBACS, even if I think you are wrong and have the statistics to prove it, but what is it about first timers that scares you so much, anyway?

Flaws In Recent Home Birth Research May Mislead Parents, Providers

September 29, 2013 03:00 PM by Nerida
Just wondering if the lack of accurate recording of Apgars in homebirths is because the baby is actually on mums chest with cord intact and still oxygenating baby etc which makes it a whole different scenario from, we have cut the cord, removed the baby from the mother and now NEED to suction and get it breathing - again are you more concerened with filling in a form or getting that baby breathing. With home birth, gentle birth the desirability of scoring a baby is less urgent. Pinking up on mother chest, burping up amniotic fluid as lungs fill and expand, in accord with the ebb and flow of the continued blood transfusion from the placenta has its own rhythm and time frame. If baby is not breathing at one minute, it is not a medical emergency if cord has not been cut and placenta is still doing its job.

Flaws In Recent Home Birth Research May Mislead Parents, Providers

September 29, 2013 03:00 PM by Nathan
The study by Grunebaum ONLY included home births done by midwives. What else but planned could these be? The CDC website also has data on planned versus unplanned births since 2007 for about 60% of deliveries in certain states. So, anyone can easily compare planned/unplanned home births. These data are open to anyone. The CDC data show that 99% of all home midwife births are planned. That means that there is clear proof that all home midwife births can be considered planned and that Grunebaum did the right thing. Why else would a midwife at home deliver a baby unless it was planned? Hospitals do not usually make errors on birth certificates. They have a special objective office that double checks data. And they get fines if their data are inaccurate. Apgar scores again and again have ben shown to be reliable on birth certificates. There are many publications saying that Apgars are reliable. Anyone finding anything to the contrary should show us. Even Wendy confirms they are reliable as does MacDorman. A 5-minute Apgar score of zero means the baby has no signs of life. Anyone who denies like Wendy does that this is not serious should never ever attend a delivery again. It's like denying the holocaust (oops I guess some crazy people do that). In the hospital these babies can sometimes (less than20% of the time) be revived with huge amount of resources (medications, intubation, umbilical catheters, specialists, NICU, cool cap etc). But often with really bad neurologic consequences. These resources are not available at home births were these babies usually die. Wendy says: @Monica, as stated above, two articles are in press regarding methods and outcomes from the 2004-09 MANA Stats registry and two more are under review The MANA statistics published do NOT show neonatal outcomes, but only certain interventions such as episiotomies. These are NOT neonatal outcomes at all, which MANA has never ever published. MANA should stop confusing "outcomes" with interventions. Outcome is a bad Apgar and/or someone dying. An intervention is not a neonatal outcome. Wendy says: "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," Not true. MacDorman's publication in 2012 showing an increase in homebirth was celebrated by MANA, but it used the exact same birth certificaTE database used by Grunebaum who just followed MacDorman's data which she herself finds reliable and has never admitted to be unreliable. Have you seen any publication by MacDorman, a home birth advocate where she says that her own CDC data on Apgar's are unreliable? No. he CDC has published numerous Apgar data report and would not have done this if they believed to be unreliable. . She has published these data many times over and they are reliable as far as Apgars are concerned. Finally, a risk of a severely affected and often dead baby with an Apgar zero of 1 in 625 is HUGE. The risk of a child dying during a car accident is about 1 in 22,000, and there are laws to use car seats. During a home birth the risk is 35 in 22,000. A huge number. The car seat here would be a hospital birth.

Flaws In Recent Home Birth Research May Mislead Parents, Providers

September 29, 2013 03:00 PM by Sarita
Thank you Wendy for your voice of reason in this world of confusing numbers. As a physician and midwife who has attended out of hospital birth for over 30 years, I am well aware of the danger of unplanned home birth, the safety of planned homebirth with a trained attendant who has direct access to medical care when needed, and the disadvantage/danger of hospital birth for low risk women. I am so excited to know that research based on MANA Stats is in the wings for publication soon. I hope that more researchers will come forth to use the data to accurately paint the picture of midwife-attended OOH. Having grown up in a culture where home-birth was the norm and hospitals were seen as a place for the sick, not the healthy, it is interesting to me to see the level of manipulation still being used to convince healthy women that they can't give birth without a trained surgeon present.

Flaws In Recent Home Birth Research May Mislead Parents, Providers

September 29, 2013 03:00 PM by Anon
Sarah, just the opposite actually. Several studies have compared typical APGAR scores given by hospital personal and OOH midwives. The hospital APGARS ranges were all over the board but nearly every Homebirth midwive APGAR was 9 & 9 or 9 & 10. Even Rixa Freeze claims her online homebirth delivery had decent APGARS, but if you time the APGAR at one minute, it is atrocious. It wasn't until 2 minutes until the baby really took a breath.

Flaws In Recent Home Birth Research May Mislead Parents, Providers

September 29, 2013 03:00 PM by Siri Dennis
Come on, assigning correct Apgar scores is hardly rocket science! No one who cannot accurately assess a newborn should be a community midwife, and if there are 'midwives' (aka birth junkies) who cannot score babies properly, that is a terrible indictment of h8mebirth midwifery. I simply don't believe that anyone would assign a score of 0 to a baby that needed a bit of help with breathing. Respiratory effort is only one of five criteria. And an Apgar score is an Apgar score whether it's 'assisted' or not. Of course babies born at home with dilettantes in attendance are less likely to receive any meaningful assistance. @Sarah Taylor

Flaws In Recent Home Birth Research May Mislead Parents, Providers

September 29, 2013 03:00 PM by Siri Dennis
Oh, the happy world of Cloud Cuckooland, where the belief in delayed cord clamping verges on the fanatical. Listen, if there were ANY reliable evidence that delayed clamping is at all useful, hospitals would happily adopt the practice. Homebirth fanatics only bleat on about it because they must be seen to be different, at any cost, not because they really think a placenta that's peeling off a rapidly contracting uterine wall has any useful functions left. And as a hospital midwife I would ALWAYS deliver babies on to their mothers' abdomens, and leave them there, unless they needed attention. Cord clamping, once the baby is out, is simply irrelevant to neonatal outcomes.

Flaws In Recent Home Birth Research May Mislead Parents, Providers

September 29, 2013 03:00 PM by Anon
In our hospital, the nurses provide a complementary certificate that the parents take home that is not a legal document. The legal birth certificate is reviewed and signed by the nurse, the delivering provider, AND the parents.

Flaws In Recent Home Birth Research May Mislead Parents, Providers

September 29, 2013 03:00 PM by Anon
Sarita. I didn't know surgeons deliver babies? General surgeons generally don't look at OBs as surgeons and most OB don't either, only the crunchy do. OB/GYN are primary care physicians caring for women from adolescence to death. Providing office annual exams, screening for disorders, caring in low risk and high risk pregnancy, and of course a limited scope of surgery. A smart person knows not to start a procedure that you cannot handle any of the common complications that arise. Heck, that goes for any profession. But home birth midwives cannot provide epidurals, vacuum, cesarean, repair of third, fourth, or cervical lacerations, transfuse blood, any many other life saving measures, yet their "trust birth". Tell any profession to "trust blank", and you'll get evil looks. I would rather hope for the best, but be prepared for the worst.

Flaws In Recent Home Birth Research May Mislead Parents, Providers

September 29, 2013 03:00 PM by Wendy Gordon, LM, CPM, MPH
@Anon, Siri Dennis and Monica -- the journal articles in press that I referred to above will include all relevant factors, including morbidity and mortality. When I say "in press", that means that the research articles are in the hands of the editors and reviewers of the journal to which they have been submitted. Most people are surprised with how long the process of peer review and publishing takes. We would like it to be faster too but welcome the process of critical evaluation by the experts doing the review. In the meantime, please refer to the Johnson & Daviss (2005) article from the BMJ for prior morbidity and mortality rates from planned homebirths attended by CPMs in 2000.

Flaws In Recent Home Birth Research May Mislead Parents, Providers

September 29, 2013 03:00 PM by Sharon Muza, BS, LCCE, FACCE, CD(DONA), BDT(DONA)
@Siri Dennis There is no doubt that there is a large body of well-respected evidence, that early cord clamping does affect the newborn; and that physiological (or delayed) cord clamping is best practice. To state otherwise is not accurate. http://www.scienceandsensibility.org/?p=5730 and http://www.scienceandsensibility.org/?p=7083 both of these posts written by pediatrician Mark Sloan provides resources that support this. Your statement "cord clamping, once the baby is out, is simply irrelevant to neonatal outcomes." is not supported by evidence for the full term nor the premature newborn.

Flaws In Recent Home Birth Research May Mislead Parents, Providers

September 29, 2013 03:00 PM by Nathan
So let's take a close look at the 5 intrapartum deaths in that famous Johnson&Daviss (2005) study that Wendy thinks is a great example of presumed wonderful neonatal outcomes in home births: Term pregnancy, transferred in first stage, cord prolapse discovered with artificial rupture of membranes in hospital 1. Term pregnancy, breech transported in second stage because of decelerations, delivered during transport: PREVENTABLE with hospital births with good sonogram AND cesarean Term pregnancy, breech, transport after birth at home: PREVENTABLE with hospital births with good sonogram AND cesarean Term pregnancy, 41 weeks five days. Subgaleal, subdural, subarachnoid haemorrhage. No fetal heart irregularities detected with routine monitoring. Apgar scores 1 and 0 : PREVENTABLE with hospital births and fetal monitoring Post-term pregnancy at 42 weeks three days, nuchal cord 6X and a true knot: PREVENTABLE with hospital births and good monitoring ALL 5 deaths were preventable with a hospital birth.

Flaws In Recent Home Birth Research May Mislead Parents, Providers

September 29, 2013 03:00 PM by Sharon Muza, BS, LCCE, FACCE, CD(DONA), BDT(DONA)
I would like to remind the S&S commenters of Science & Sensibility's policy if you would like to continue to comment on this post. http://www.scienceandsensibility.org/?page_id=1662 Community Manager, Contributors (guest and regular) and Commenters shall abide by the following policies in their interactions on this blog site: All blog post articles designed to present statistical information or offer best practices advice for maternity care professionals must be consistent with up-to-date, evidence-based research and/or be consistent with Lamaze International?s Six Healthy Birth Practices. Comments on blog posts must be constructive and non-inflammatory. Critiquing and debating is appropriate; defaming and attacking is not. Comments should be relevant to the topic of the blog post and/or the comments of other participants. Comments posted to Science & Sensibility (dissenting or confirming) do not necessarily reflect the ideals or viewpoint of the blog Community Manager, contributors, or Lamaze International. Posted comments that fail to uphold these policies may be removed by the sole discretion of the Community Manager in effort to maintain the professional nature of this blog site. I will not tolerate disrespect, baiting or comments that do not support professional and respectful dialogue. Comments will be deleted without warning. Feel free to post elsewhere on the internet if you can not abide by our posted policy.

Flaws In Recent Home Birth Research May Mislead Parents, Providers

September 29, 2013 03:00 PM by Wendy Gordon, LM, CPM, MPH
Anon : I see that this study that Wendy finds to be flawed also correlates with Judith Rooks research into the Oregon Homebirth statistics. Can Wendy please comment on Judith Rooks findings? The Grunebaum study does not examine deaths, so there is no correlation to be made here. However, with regard to Judith Rooks' analysis of preliminary Oregon data, it is important to look at the facts closely. I would ask readers to review the state's data that was published shortly after Ms. Rooks' letter (the state's data may be found here), also with preliminary 2012 data. There is a large discrepancy between Ms. Rooks' estimated fetal death rate in planned hospital births and the state's actual data, which unfortunately led to the erroneous conclusion that the mortality rate for planned home births was 6-8 times higher than that for planned hospital births. The actual data shows a two-fold difference, which still certainly deserves attention and close examination, but describes a different alarm scenario. While it is critically important for all maternity care providers to carefully evaluate the safety of their practice, the very low number of both births and deaths in Oregon for one year in the planned home birth group makes it difficult to draw meaningful conclusions about safety. A misclassified death in the homebirth group causes the mortality rate to swing dramatically, while a similar misclassification on the hospital side has essentially no effect. To illustrate this, babies born with lethal congenital anomalies are typically excluded in studies that look at the safety of location of birth, as I mentioned in the article above. In the Oregon data, there was one baby born with a lethal anomaly in the planned out-of-hospital group, and the exclusion of that one death makes a large difference in the mortality rate when there are only ~2000 home or birth center births to start with. When you try to break this down even further by type of provider for planned home or birth center births, comparisons become impossible; for example, the mortality rate for midwives who are also naturopathic doctors (NDs) was either 4.6/1000 if that particular baby with the lethal congenital anomaly was attended by an ND, or the rate was 0/1000 if that birth was excluded from the data. There are no meaningful conclusions that can be drawn with either of these rates in a very small sample. One misplaced number can have a dramatic effect, so the rates must be used with extreme caution. I believe that midwives are eager to understand what the evidence has to say about the safety of our model of care and the location of birth, and as Oregon continues to collect this data, the midwives there should be able to see more clearly where changes may need to be made.

Flaws In Recent Home Birth Research May Mislead Parents, Providers

September 29, 2013 03:00 PM by Nathan
@Nerida "If baby is not breathing at one minute, it is not a medical emergency if cord has not been cut and placenta is still doing its job." Apgar zero means baby is not breathing, not moving, no heart beat. That is dead by any definition. Whoever believes that is normal should not get close to babies.

Flaws In Recent Home Birth Research May Mislead Parents, Providers

September 30, 2013 03:00 PM by Anon
@Wendy, wasn't the Johnson and Davies study found to be flawed because it compared contempory Homebirth outcomes with decade old hospital outcomes? And of course, no one can take out the biased reporting since both Johnson and Davies either are or work with Homebirth midwives.

Flaws In Recent Home Birth Research May Mislead Parents, Providers

September 30, 2013 03:00 PM by Siri Dennis
@Sharon Muza No, that is not correct; the ONLY (small) benefit from delayed cord clamping is slightly higher iron stores in babies of 3-6 months. DCC has NO impact on Apgar scores, admission to NICU, respiratory distress, breastfeeding success or neonatal anaemia. So the idea that leaving the cord intact can support a struggling newborn, or retrieve a compromised one, is FALSE and dangerous. If incompetent midwives are managing emergent situations by simply omitting to clamp and cut the cord, no wonder homebirth outcomes are so poor. Leaving the cord in place is NOT a lifesaving or brainsaving intervention! And if midwives believe it is, and tell parents that it is, that is not safe, or acceptable, or in any way defensible. Babies of 6 months can get sufficient iron from their weaning diet (if they need it, which the vast, vast majority do not, despite having had their cords clamped and cut immediately - there IS no epidemic of anaemic 6-month-olds out there); neonates CANNOT get sufficient oxygen from their placentae.

Flaws In Recent Home Birth Research May Mislead Parents, Providers

September 30, 2013 03:00 PM by Siri Dennis
I am horrified, really horrified, to hear people talk about delayed clamping as if it's some kind of lifesaving manoeuvre; the ignorance and misinformation is truly staggering. Anyone hoping to improve homebirth safety faces a mammoth task when it comes to dislodging these dangerous myths and replacing them with truly evidence-based thinking. Leaving a cyanosed infant with his cord intact thinking that is what is needed is just as irresponsible as trying to stop a post-partum haemorrhage with cinnamon. I have given birth at home, with skilled, experienced and knowledgeable community midwife, and I can tell you, if they thought there were any benefit in DCC, they would have incorporated it into their practice. Hospital guidelines change all the time in response to new research and new knowledge; examples include episiotomies, once routine, now very rare; shaving of genitals (ditto); enemas (ditto). My hospital even stopped bathing neonates immediately after birth in case it interfered with breastfeeding and bonding! If a practice is found to be harmful or pointless, it gets discarded. If another practice is found to be beneficial, it's included. In fact, hospital guidelines are much more flexible and responsive than some homebirth midwives' practices, which tend to be very firmly entrenched and almost impossible to dislodge (eg prayer as an intervention, delayed cord clamping, the idea that epidurals are harmful to the baby, the idea that hospitals are horrible, dangerous places full of staff with evil intentions, etc.). If homebirth midwives were half as ready to move with the times as hospital staff are, we would have a very different situation on our hands. Different, and much, much safer.

Flaws In Recent Home Birth Research May Mislead Parents, Providers

September 30, 2013 03:00 PM by Susanrachel Condon
Thank you! Nicely done and timely.

Flaws In Recent Home Birth Research May Mislead Parents, Providers

September 30, 2013 03:00 PM by MomOfMore
@Wendy Gordon, LM, CPM, MPH I'm confused. Intrapartum and neonatal mortality rates in the BMJ were 1.7 per thousand. That's 1 in 588ish low risk women under CPM having her baby die either in labor or in the newborn period. Numbers that high on an absolute level were never disclosed to me during any informed consent discussion with either midwife during any of the three home births I chose. I was told "as safe or safer than," not "1 in 588 low risk mothers under the care of a CPM had her full term baby free from congenital anomalies die." I need a better citation than the ones provided by the authors of the 2005 study to demonstrate that planned hospital birth for low risk mothers of, singleton, vertex, full term infants free from congenital anomalies carries a risk similar to a 1 in 588 rate of intrapartum or neonatal death. Does anyone have a citation like that? I would really appreciate it.

Flaws In Recent Home Birth Research May Mislead Parents, Providers

September 30, 2013 03:00 PM by Liz
Momofmore, you can look up the data yourself on the CDC wonder database. A quick look at the death rate in days 1-6, excluding premies, post-dates, and twins, but not pre-E, GD or breech, is about 0.34 in 1000 in the hospital.

Flaws In Recent Home Birth Research May Mislead Parents, Providers

September 30, 2013 03:00 PM by moto_librarian
"Two articles are in press and two more are under review in peer-reviewed journals." Clearly, you don't understand much about academic publication. If an article is "in press," that means it has been published. If it is not available to the public, it has either been "accepted for publication" or is "under review." I tend to believe that if the MANA data proved that homebirth was as safe as Wendy Gordon asserts, it would have been published long ago. None of your arguments are even remotely compelling. If anything, the number of deaths related to homebirth are likely undercounted, since a baby that dies during transfer will be attributed to the hospital's statistics. You claim that families need "the best information" for making decisions about where to have their babies. If you really believed this, you would make the MANA stats regarding perinatal mortality available.

Flaws In Recent Home Birth Research May Mislead Parents, Providers

September 30, 2013 03:00 PM by Wendy Gordon, LM, CPM, MPH
@MomOfMore, you can find a large bibliography of studies about the safety of home birth here. If you use the CDC WONDER database in the way that Liz suggests, you will only get the neonatal death rate, not the intrapartum + neonatal rate as you asked. It's difficult to use that database to get to a hospital comparison group that is adequately matched to the home birth group, but you can try. An actual research study might hold more water though.

Flaws In Recent Home Birth Research May Mislead Parents, Providers

September 30, 2013 03:00 PM by MomOfMore
@Wendy Gordon, LM, CPM, MPH Thanks for the link, Wendy. Does that mean that you affirm the findings of the BMJ 2005 study regarding intrapartum plus neonatal mortality, out of curiosity? That you feel the 1 in 588 number is an accurate reflection of the rate of full term, intrapartum or newborn death in singleton infants presenting vertex while under the care of a CPM during this time period? I'm asking because I'm looking at one of the studies in the link that seems particularly well done and it gave a perinatal mortality rate of .35/1000 (1 in 2857ish) for planned out of hospital birth with a midwife and .57 (1 in 1754ish) for in hospital birth with a midwife. Is there a reason that I'm missing regarding in terms of why the Canadian home birth midwife perinatal death rate should not be compared to the CPM 2005 perinatal death rate? Those death rates are significantly different, almost 5 times higher for the US vs for Canada. Is there a reason why home birth in the US and home birth in Canada should not be compared? But if that is the case, why would a review of home birth safety in Canada be relevant to a discussion of home birth safety in the US with a CPM? Thank you for your help and your response in advance.

Flaws In Recent Home Birth Research May Mislead Parents, Providers

September 30, 2013 03:00 PM by MomOfMore
@MomOfMore I apologize, I meant to include the link. It actually appears that one of the study's main authors was also one of the main authors of the BMJ 2005 CPM study? "Outcomes of planned home birth with registered midwife versus planned hospital birth with midwife or physician Patricia A. Janssen, PhD, Lee Saxell, MA, Lesley A. Page, PhD, Michael C. Klein, MD, Robert M. Liston, MD, and Shoo K. Lee, MBBS PhD" http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2742137/

Flaws In Recent Home Birth Research May Mislead Parents, Providers

September 30, 2013 03:00 PM by Wendy Gordon, LM, CPM, MPH
@MomOfMore, I'm not sure what you mean when you ask whether I "affirm the findings" of anything. You asked for citations and I pointed you to a link. The Johnson & Daviss study reported outcomes from one year of data collection using MANA Stats. Their report is reflective of the data that was collected that year; you can read for yourself what the outcomes were, as every death was described in some detail in the article. I'm not sure what you're trying to get me to say here. The Janssen study that you cited (BTW, you can see that neither "Johnson" nor "Daviss" were authors on that - ?) was a very well-designed study where the same midwives attended births in both the home and hospital settings, and had better outcomes at home. There are large differences between healthcare systems and data sources that may be important when making comparisons between Canada and the U.S. -- this has not been well-studied, but the fact that midwives and home birth are well-integrated into the Canadian maternity care system, while CPMs and home birth have been prohibited from similar integration in the U.S., might be important. Teasing apart the similarities and differences between home births and the practice of midwifery in different countries and healthcare systems is complex and not well-researched. Poorly-designed studies such as Grunebaum's do little to advance our understanding.

Flaws In Recent Home Birth Research May Mislead Parents, Providers

October 1, 2013 03:00 PM by MomOfMore
@Wendy Gordon, LM, CPM, MPH I somehow mentally transposed "Johnson" and "Janssen." Thank you for the correction. I disagree that Grunebaum's study doesn't add anything to advance our understanding about home birth in the United States. It seems like the research in other countries demonstrates a significant degree of home birth safety, particularly for low risk multiparas. It is increasingly unclear to me that home birth in the United States operates under the same safe conditions present in other countries. There are definitely weaknesses in the Grunebaum study, but I do not see how those weaknesses add up to a 10x different relative risk, and the research by Judith Rooks showing similar increased risks further confirms my unease. The magnitude of difference is too high. By the way, Judith Rooks's sample size is admittedly small for the home birth population, but would it be fair to use her computation of in hospital perinatal mortality rates, albeit knowing that they do not remove infants with congenital anomalies? The rate she gave was .6/1000, which is roughly the same as the average of midwife attended and MD attended in hospital perinatal death in the Canadian study. The best source for perinatal mortality would undoubtably be the MANA stats, to which I have contributed 3 births. Is there a way for me as a home birth mother to get a pre-publication copy of the two studies you have stated are in press?

Flaws In Recent Home Birth Research May Mislead Parents, Providers

October 1, 2013 03:00 PM by another anon
@MomOfMore MomOfMore : @Wendy Gordon, LM, CPM, MPH Is there a reason that I?m missing regarding in terms of why the Canadian home birth midwife perinatal death rate should not be compared to the CPM 2005 perinatal death rate? Those death rates are significantly different, almost 5 times higher for the US vs for Canada. Is there a reason why home birth in the US and home birth in Canada should not be compared? But if that is the case, why would a review of home birth safety in Canada be relevant to a discussion of home birth safety in the US with a CPM? Thank you for your help and your response in advance. Canadian midwives are not comparable to CPMs. In the provinces where they operate legally, they are well-integrated into the healthcare system and attend both in-hospital and out-of-hospital births. Additionally, they are required to have at least a four-year university degree in midwifery and a practicum period before they can practice independently. An American CPM meeting the current minimum CPM standards would not be qualified to practice in Canada (recognizing that many CPMs exceed the minimum requirements). The more apt comparison between Canadian and American outcomes would be between Canadian midwives and American CNMs. Both have advanced, university-level education as a requirement for licensing. Given the extensive differences between the nature of the health care systems and the qualifications of practitioners, I would not be comfortable using the results of studies about Canadian midwives to justify homebirth with an American CPM.

Flaws In Recent Home Birth Research May Mislead Parents, Providers

October 1, 2013 03:00 PM by moto_librarian
@Anon They are not "in press" if they are not yet published. At best, they are "pending publication" or "under review." At worst, they have been "submitted for publication."

Flaws In Recent Home Birth Research May Mislead Parents, Providers

October 1, 2013 03:00 PM by M Sonntag
@moto_librarian "In press" means the article has passed peer review and been accepted for publication, but the journal has not yet published it - you will typically see it within the next 1-2 editions of the journal (most publish monthly). This is very standard terminology. Sometimes "in press" articles or abstracts are made available online prior to print publication, but that is certainly not always the case. "Pending publication" and "in press" are synonymous.

Flaws In Recent Home Birth Research May Mislead Parents, Providers

October 1, 2013 03:00 PM by M Sonntag
@MomOfMore MoM, I don't think - based on this one study - that we can hang our hats on the 1 in 588 rate for OOH births, so there's not much point trying to find studies (or better yet, meta-studies) showing a comparable the Apgar of 0 at 5 min rate for planned hospital births. Apgar at 5 is just not a common metric, and the most likely reason these authors used it is because birth certificates are widely available and easy to analyze. But they are notoriously inaccurate (see http://www.ncbi.nlm.nih.gov/pubmed/16055587 for just one example, or spend an afternoon on PubMed for many more examples). I think most would agree that a ten-fold difference is concerning. But this study has many design flaws, as outlined by Wendy Gordon. The best we can conclude from this study is that more (and better-designed) studies are needed, or perhaps a meta-study including this one. The Oregon report that you cite is also potentially concerning; though the numbers are small, the differences are statistically significant (yes, I actually performed a chi square and got a p of 0.01). Due diligence: the Oregon report has not undergone peer review, and even Rooks herself concludes that more research is needed. Of the studies linked on the MANA website, the 2005 Johnson report seems to me the most informative for US births, but they didn't include a comparison group in the study, and the most recent reference they cited stating that the in-hospital and OOH rates were similar actually does not support their assertion (http://www.ncbi.nlm.nih.gov/pubmed/12151146?dopt=Abstract&access_num=12151146&link_type=MED). The rest of the studies are pertinent to other countries - as you say (and I agree), they show that planned homebirth can be safe, but can't show that planned homebirths in the US - as a whole - are as safe (mortality-wise) as planned hospital births. The best information I could find on the overall intrapartum neonatal death rate in the US is 0.95 and is specific to the year 2000 (http://www.who.int/bulletin/volumes/83/6/409.pdf). So... 1.6 is higher, but 0.16 seems implausibly low. Whether the difference turns out to be 10-fold, 2-fold or nonexistent, it's still up to each family to decide what level of risk they are comfortable with. In short, and imho, we really need more well-designed studies. I'm very much looking forward to reading the "in press" articles! (For the record, I've had both a planned in-hospital birth and a planned OOH birth with a CPM).

Flaws In Recent Home Birth Research May Mislead Parents, Providers

October 1, 2013 03:00 PM by Wendy Gordon, LM, CPM, MPH
MomOfMore : There are definitely weaknesses in the Grunebaum study, but I do not see how those weaknesses add up to a 10x different relative risk, and the research by Judith Rooks showing similar increased risks further confirms my unease. The magnitude of difference is too high. By the way, Judith Rooks?s sample size is admittedly small for the home birth population, but would it be fair to use her computation of in hospital perinatal mortality rates, albeit knowing that they do not remove infants with congenital anomalies? The rate she gave was .6/1000, which is roughly the same as the average of midwife attended and MD attended in hospital perinatal death in the Canadian study. To clarify, neither Judith Rooks nor the State of Oregon conducted "research" -- they reported data. As you can see in Ms. Rooks' analysis, she used an estimate of hospital death rates, which unfortunately was vastly lower than the state's actual hospital data. While I hear that some folks here are really wanting to stick with Ms. Rooks' analysis, I think that we would all be better served in our search for understanding if we used actual data rather than estimates. The Oregon State data does not correlate with Grunebaum's data; nothing does. This Apgar study is out in left field all by itself, and in fact is exactly the opposite of what many other well-designed studies have found (citations listed in my article above). Another issue that can be confusing when trying to compare absolute numbers from studies is that different studies use different definitions of death rates. Readers have to be very careful to make sure that the rates they are comparing are actually apples and apples. For example, the de Jonge (2009) Netherlands study reports an intrapartum (IP) death rate, an IP + neonatal death rate in the first 24 hours of life, and an IP + neonatal death rate for the first 7 days of life. Johnson & Daviss (2005) report an IP + neonatal death rate in the first 28 days of life. Janssen (2002 & 2009) report a perinatal death rate that covers deaths from 20 weeks of pregnancy through the first 7 days of life. The Birthplace in England study (2011) reports a neonatal death rate in the first 7 days and a perinatal death rate that is defined similarly to Janssen. Kennare (2009) reports a perinatal death rate of 20 weeks of pregnancy through 28 days of life. Some studies included higher-risk births such as preterm, post-term, breech, twins and VBACs. Some don't. So when trying to make sense of the numbers, we have to look very closely at what the numbers really mean, how they were derived and who they are talking about. The Oregon State report used an unusual definition: term fetal deaths (>37 weeks) and term early neonatal deaths (first 6 days of life). Honestly, I'm not sure how to advise that you use these data to make comparisons with other studies; it doesn't really correlate with the definitions that most studies have used. I can't be certain how Ms. Rooks examined her data; she doesn't define this in her letter to the Oregon state legislature. It appears that she used the state's "term fetal deaths + early neonatal deaths" data for the out-of-hospital group, but for the hospital group, she used her estimate of intrapartum deaths (which was interestingly... zero) plus early neonatal deaths for the hospital group. I think it's hard to make honest comparisons between two groups when you use different criteria for each of them. And when we broaden that out to look at different studies and different countries and healthcare systems... there are a lot of factors to consider. But what seems to be clear, time and time again in the most rigorous studies on homebirth safety, is that for women with healthy low-risk pregnancies, there is no increased risk of death (however that is defined in those studies) between planned home and planned hospital births -- and that risk is very low -- with much lower rates of interventions at home with midwives. When we include unplanned and/or unattended home births (Pang, Wax, Malloy) or women with higher-risk pregnancies (Kennare and others), some differences start to sift out. We have to be very careful about how we evaluate this information; there are many varieties of apples and oranges.

Flaws In Recent Home Birth Research May Mislead Parents, Providers

October 1, 2013 03:00 PM by Kim Lane, CPM, LM
@Another Liz I completely agree with you, Liz!

Flaws In Recent Home Birth Research May Mislead Parents, Providers

October 1, 2013 03:00 PM by Kim Lane, CPM, LM
@Sarita Amen... & ... Awomen! ;)

Flaws In Recent Home Birth Research May Mislead Parents, Providers

October 2, 2013 03:00 PM by Siri Dennis
Yes, it IS interesting that the OOH intrapartum death rate is zero. Could this be because homebirth midwives are incapable of diagnosing intrapartum death? We read so many birth stories where 'fetal heart tones were good' until the baby dropped dead into the midwife's hands. Or fatally compromised, destined to die in hospital and be counted in hospital statistics. @Wendy Gordon, LM, CPM, MPH

Flaws In Recent Home Birth Research May Mislead Parents, Providers

October 2, 2013 03:00 PM by Wendy Gordon, LM, CPM, MPH
@Siri Dennis, you may want to re-read the letters, articles and comments that you're responding to before you hit the send button.

Flaws In Recent Home Birth Research May Mislead Parents, Providers

October 2, 2013 03:00 PM by Siri Dennis
Touche! I was too hasty that time...my bad.

Flaws In Recent Home Birth Research May Mislead Parents, Providers

October 2, 2013 03:00 PM by Siri Dennis
Though I'd still appreciate an explanation of exactly how delayed cord clamping saves babies' lives and brain function... how does it improve Apgar scores, reduce admission to NICU etc?

Flaws In Recent Home Birth Research May Mislead Parents, Providers

October 4, 2013 03:00 PM by deena chamlee
@Wendy Gordon, LM, CPM, MPH Wendy, I worked with the Oregon Affiliate and with Judith. I also practiced in Portland at OHSU and Kaiser. Not to base ones opions on transports only, however, the climate was hostile because of the morbidity and mortality regarding high risk ooh births. I have never experienced anything like it in my entire career. Groups called MAD AS HELL MOMS which consisted of mothers who lost babies. Protest rallies by families who had lost babies at homebirths, pictures on signs of their dead babies. I mean 20- 30 families. Lawsuits by cpms against the regulatory direct entry board when disipline was attempted. Lawsuits by cpm owned birth center against OHSU when an attempt to address morbidity and mortality was made. I was contacted on Facebook by moth ers wanting to tell me their traumatic homebirth loss stories. Lawsuits against the state of Oregon by a mother whose baby siffered significant encelphalopathy from hypoxia at a cpm attended birth. And it goes on and on. I don't care about the numbers debate I lived it! Trust me we have major issues to address nationally.

Flaws In Recent Home Birth Research May Mislead Parents, Providers

October 5, 2013 03:00 PM by M Sonntag
@deena chamlee There are also mothers in Oregon who have lost a baby at a home birth who do not agree that home births are more risky, are not members of Mad as Hell Moms, and in fact are attacked online and silenced by those groups. It's a highly polarized debate, but the loudest voices are not always in the right - sometimes they are just louder. That's why we NEED numbers. We can't base policy on whomever is shouting the loudest (witness the current state of the American government).

Flaws In Recent Home Birth Research May Mislead Parents, Providers

October 5, 2013 03:00 PM by deena chamlee
@M Sonntag @M Sonntag As I said, I have never and I mean never be exposed to anything as sad. I have never experienced a complete and total consuming feeling of total depression as I did back in May of 2011. The numbers are needed and I am working on writing a paper. The birth data by state may be limited to only those states who collect outcomes on home births.Thus, limiting over all sample size. The CDC Wonder isn't the best but I do feel that querring the database could possibly assist with understanding what in the world is occuring and why. Gestaltly, I feel outcomes are directly related to educational standards, state regulations and inclusion and exclusion criteria. In hospital providers also must take some responsibility for not offering informed choice at in hospital settings. And for not supporting midwifery led services so informed choice can be offered. Multifactorial, complex and heartbreaking. I am telling you the mortality and morbidity rate in Oregon was horrific. If it wasn't I certainly would not have experienced such a hostile environment. And it was unfathomable.

Flaws In Recent Home Birth Research May Mislead Parents, Providers

October 9, 2013 03:00 PM by Melanie
Siri, I am not a midwife but I am a HypnoBirthing childbirth educator. Cord clamping has become a big deal. Studies have been done on small animals which have had the cords clamped immediately and during autopsies, they have found that their brains (specifically frontal lobes)showed contusions- this would be the same result in a human who was strangled to death. The part of the brain does not get enough oxygen and small parts begin to die. Is it any wonder there is a 47% increase in learning disabilities with standard cord clamping? When baby is born, 30%-50% of it's blood is still in the placenta and cord. If baby does not get all or more of that blood, its little body is going to have a very hard time filling up those flappy little lungs to start working. If baby can't draw blood from other areas of its body fast enough to fill up the lung tissues, then it will experience "respiratory distress" and be taken away, missing out on optimal bonding time with its parents. The cord is there as a secondary oxygen source while baby learns to breathe on its own- this is a new experience for baby and does not come immediately. Babies transition into breathing as much as everything else.It might only take 20 seconds but those are some important 20 seconds!

Recent Stories

What's New in The Journal of Perinatal Education? July 2016 Update


Five Black Birthworkers Receive Awards to Honor Their Contributions in Improving Birth Outcomes for Families of Color.


Gene Declercq, PhD and Birth by the Numbers Look at Home Birth Trends - The Results May Surprise You!