Henci Goer - Fact Checking the New York Times Home Birth Debate

home birth

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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

References

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

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.  

21 Comments

@Knitted in the Womb Here is a

February 26, 2015 07:00 AM by Henci Goer, BA
@Knitted in the Womb Here is a quote from Cheyney 2014a: "The data collection design for MANA Stats hinges on preregistration, or prospective logging, of all clients. Each midwife contributor is given a password-protected account to use for secure access

At least one midwife who submi

February 26, 2015 07:00 AM by Knitted in the Womb
At least one midwife who submitted data to MANA during 2004-2009 (Navelgazing Midwife) says that data was not collected during pregnancy, but rather post partum. So it most certainly could have been possible to omit "poor outcome" data. I've had 4 homebirths, so I really support the option. But this flaw in the data collecting does concern me. I'd like to see the data re-evaluated with it being collected as it was explained here--women being entered into the database during pregnancy.

@D. Lane Please get back to S&

February 26, 2015 07:00 AM by Henci Goer, BA
@D. Lane Please get back to S&S if they print it!

I left the following comment a

February 26, 2015 07:00 AM by D. Lane
I left the following comment at NYT: Americans are 16X more likely to die on a car trip than on a plane flight to the same destination, yet we don't consider requiring parents to fly with their children rather than drive them. We accept as a matter of course that there are many situations where the advantages of driving outweigh the increased safety of flying. For low-risk women, both hospital births and home births with trained attendants are very safe. And even if it were true that hospital births were safer for most women, there would still be some women for whom the unfamiliar environment and interventions of the hospital could interfere with the progression of labor and result in a less safe experience for her and her baby. Women should, of course, be well informed about the risks inherent in their choice of birth location, but home birth with trained attendants and continuity of care when transport becomes necessary should be an option for women who prefer it.

Thank you, Henci!

February 26, 2015 07:00 AM by Chloe
Thank you, Henci!

"vital statistics data arenƒ??

February 27, 2015 07:00 AM by Doula Dani
"vital statistics data arenÉ??t reliably accurate, donÉ??t permit confident determination of intended place of birth, and donÉ??t follow transfers of care during labor." That's not true. This is a claim I have read many times in home birth propaganda but it is not supported by evidence. There are certain aspects of vital statistics data that are not as accurate but they are highly accurate for APGAR scores and for neonatal deaths. I have read the Citizens for Midwifery "fact sheet" and the studies included regarding this issue. I did not see anything in the literature to support the claim that neonatal mortality information would be incorrect. So I contacted the CDC about this. The infant mortality contact (who is an author to several of the studies) said "the accuracy of reporting of neonatal death is high." (direct quote, I have the email saved) Also, place of birth is captured and attendant. In the Grunebaum studies, if a midwife did not attend the birth or if it was unknown, they did not include the data. It is a limitation, though, in that any home birth transfers that resulted in death would be included in the hospital data, not the home birth data.

https://olis.leg.state.or.us/l

February 27, 2015 07:00 AM by Melinda
https://olis.leg.state.or.us/liz/2013R1/Downloads/CommitteeMeetingDocument/8585 The data collected by the state of Oregon shows that homebirth there is not safer.

53 per 10,000 is about 5 per 1

February 27, 2015 07:00 AM by Niemand
53 per 10,000 is about 5 per 1000 or 0.5%. That's a horrifically bad neonatal mortality rate for healthy, term, vertex, singleton babies. So if your numbers are correct, they demonstrate that home birth is NOT safe, not even for the lowest risk group. One question about your methodology as well: You say that births are not lost to follow up because they are registered during pregnancy. That's great, but what if the midwife does not register the outcome. Do you have a mechanism for finding out what happened to these patients, i.e. whether they transfered to another service, were lost to f/u--or had a bad outcome that the midwife did not with to acknowledge?

The Dutch study? The Dutch stu

February 27, 2015 07:00 AM by Lilly
The Dutch study? The Dutch study is irrelevant to American homebirth practices, as Dutch midwives are governed by strict risking out protocols to which they are legally required to adhere AND Dutch midwives have graduate level degrees in nursing and midwifery. American homebirth midwives are not required to have anything beyond a high school diploma and the CPM certification requirements are minimal at best. Additionally, American homebirth midwives are not governed by any risking out protocols, and in fact MANA rejects them in favor of "midwife autonomy." Therefore, comparing American homebirth midwives to Dutch homebirth midwives is comparing apples to oranges. Lastly, the Dutch studies who that low risk Dutch women delivering at home have higher perinatal mortality rates than high risk Dutch women delivery with OB/GYNs in hospitals, a fact that has scandalized the Dutch government. Henci Goer's piece is intellectually dishonest.

I've been a homebirth and midw

February 27, 2015 07:00 AM by Another Liz
I've been a homebirth and midwifery supporter for a long time. But I'm so tired of this song and dance about homebirth being as safe as hospitals when it comes to neonatal mortality. I appreciate critical thinking and reasoned dialog. But it is glaringly absent in these types of discussions. The MANA study?! Really?!? You're going to trot out the MANA study in defense of homebirth being safe? The results are deplorable! Not only does it demonstrate a higher death rate for infant *among low risk pregnancies* - it demonstrates an even higher risk for births that are not low risk (breech, VBAC). This tells us that CPMs do not adhere to risk-out criteria and that they are married to some ideological philosophy that puts their birth experience (ie the midwives' experience attending a birth) over the health, safety and welfare of mothers and babies. The MANA study?!?! Come ON! This kind of crap is why I am no longer a member of MANA. They need to get it together, and act as if they exist to serve their clients instead of themselves. If you have some sort of citation that demonstrates the safety of home birth - or circumstances under which home birth is safest, I would love to read about it. But enough of this "home is as safe as the hospital" charade. It's not. And it's especially NOT the way current American midwives are practicing. If MANA is interested in promoting home birth and alternative forms of maternity care, MANA needs to start addressing where midwives fall short in providing safe care, and work to create safe practice standards so ONLY the lowest risk clients are attempting home birth. MANA needs to address the utter lack of educational standards for CPMs and advocate for ONLY skilled, trained and licensed midwives to be attending births. MANA needs to take its head out of the sand and start addressing the REAL issues around homebirth. It's not big, mean, nasty OB/GYNs. It's themselves!

Other questions about Grunebau

February 27, 2015 07:00 AM by josh
Other questions about Grunebaum and Chervenak... Why were the mortality rates in their study so low (across all conditions ~0.3-2.0) in comparison to the US average (~6.1)? Did they significantly undersample homebirths in their study relative to the % of homebirths that actually occur in the US? If so, where did those homebirths go? Could they of had a higher probability of being healthy- changing the results of the study?

https://olis.leg.state.or.us/l

February 27, 2015 07:00 AM by Melinda
https://olis.leg.state.or.us/liz/2013R1/Downloads/CommitteeMeetingDocument/8585 The data collected by the state of Oregon shows that homebirth there is not safer.

I am blogging about the series

February 28, 2015 07:00 AM by Elizabeth Fox
I am blogging about the series, starting with an extensive critique of Grunebaum and Chervenak: https://humanwithuterus.wordpress.com/2015/02/28/the-anti-home-birthers-alternative-to-home-birth/

data to draw sweeping conc

February 28, 2015 07:00 AM by The Anti-Home-Birthers? Alternative to Home Birth | human with uterus
data to draw sweeping conclusions?ˇabout home birth outcomes has been broadly criticized (e.g. here, here, and [?]

Henci, Thank you for the MANY

March 1, 2015 07:00 AM by Vicki Hedley, CCE, CD, PCD, LCCE
Henci, Thank you for the MANY years of clear-thinking, well-supported reviews of the research you are doing on behalf of mothers and babies. vicki

@Elizabeth Fox @Elizabeth Fox.

March 1, 2015 07:00 AM by Susan Jenkins
@Elizabeth Fox @Elizabeth Fox. Thank you for your excellent research and expose of the conditions under which women give birth at NY Presbyterian-Cornell! This is the kind of information that the readers of the NY Times need to see. Human with Uterus is o

Thank you Henci for writing ab

March 1, 2015 07:00 AM by Treesa
Thank you Henci for writing about the complicated issues of reading studies, and interpreting the results. It is important that research continue, that we develop better and more complete tools to look at birth in America. Obviously using data from the birth certificate is not an accurate source of information for many births. We need to keep in mind as we look at the data, that ultimately women will decide where and with whom to give birth. Blogs like this from Henci Goer will provide them with valuable information with which to judge the evidence for themselves.

Thank you, Henci! I only wish

March 2, 2015 07:00 AM by Carrie Sparrevohn
Thank you, Henci! I only wish the NYT would publish this as a rebuttal.

Hi Henci, Great to read this r

March 11, 2015 07:00 AM by pat marjavi
Hi Henci, Great to read this rebuttal. As a 30-year L&D RN and a homebirth advocate as well as a mother of 2 home-born children, I think low-risk women and babies are safer at home where there is less intervention and much less fear of the physiologic process. I also assisted at homebirths and felt there was much greater risk for women in the hospital. We have to keep on educating women re their options and support their choices. RNs need to be strong advocates for women who want natural childbirth in the hospital. It's interesting how "natural" childbirth has become conflated with vaginal delivery. Let's keep on keepin on!

Hospital births were an unusua

March 17, 2015 07:00 AM by Kellie A. Sparkman CPM LM
Hospital births were an unusual experiment with an inexcusable death rate...something like 75 pr thousand...that is why some women stayed home and started helping their friends with natural births...Hard to say how hospitals improved their statistics...I can think of a lot of creative ways to change the numbers...I've been a midwife for 25 years and attended 7 of my grandbabies, so I am a 'believer' BUT we 'homebirth' midwives need to up the standards. There is a lot that we could improve. LOVE...Kellie

So disappointing

March 17, 2017 05:32 AM by Lunarmama

It's ironic to me that you end the article by talking about how those are against home birth have simply "made up their minds" and are uninterested in "facts". Somehow you seem to think you're free of bias. Nowhere here do you prove that home birth is as safe as hospital birth, yet you still say you're "willing to bet" the results would support your hypothesis if slight differences were made. Your conclusion that home birth is as safe as hospital birth is based on an ideologically predisposed hypothesis, not facts. Home birth may be as safe as hospital birth in some other countries, but there is no study that shows that to be the case in the US. If you care so much about this issue, you should focus your energies on making it safer here, rather than ignoring the failures of home birth in this country. Your bias is readily apparent, but like a fish in water you can't or don't want to see it. I say this as someone who used to support home birth and changed my mind after looking more carefully at the actual data, not just taking someone else's word for it.

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