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Causes of homebirth deaths?

post #1 of 16
Thread Starter 
I have been researching homebirth and am very excited about it as an option. Having read the most recent studies from the Netherlands and British Colmbia which affirm that homebirth is as safe if not safer than hospital birth, I still wonder if the few infant deaths per 1,000 at home could have been avoided if it had been with a midwife at a hospital with an OB down the hall? I wonder if these situation could have been avoided and the baby saved, or if there was nothing that a hopsital could have done to save the baby? Anyone know of any stats or research about the causes of homebirth infant deaths? In the US, the top 3 main causes of hopsital deaths for infants are congenital abnormalities, low birth weight/not full term, and SIDS. Thoughts?
post #2 of 16
First, I can't answer your question specifically.

Otherwise--you've read the most recent studies, and have seen that planned, attended homebirth is at least as safe as hospital birth in terms of fatalities: no more babies (or mothers) die at home than in the hospital. And, you've seen that more babies and mothers DO suffer various kinds of harm in the hospital, much more often, than occurs at home.

Even though I don't know the specific answer to your question, I can say this: it seems possible, or even likely, that some tiny percent of babies die at homebirth particularly *because* they did not have medical care close-enough to help them at a critical moment (though this reason for infant death at homebirth is very unusual). BUT--by the same token, we do know that some babies die (or are harmed) in hospitals DUE TO HOSPITAL PRACTICES....due to protocols, drugs, surgeries, interventions on laboring/birthing moms and newborns, that never happen at home. Die or are harmed due to medical things that mostly CAN'T happen at home--since midwives don't do surgery, or carry epidurals and other drugs/tools with them.

Life does not give us any guarantees, no matter what precautions we take. We can only look at the facts and decide what seems safest to ourselves in choosing where and with whom to give birth. No one wants to lose a baby, or to have their baby (or moms) suffer any form of harm, whether minor harm that passes off quickly, or more longterm/permanent harm. For myself, and most others who choose homebirht (I'd guess 'most', anyway), I'd rather risk the risks of homebirth--sticking as much as possible to nature's ways--than take on the risks of hospital birth. We know that some babies die, or have problems relating to birth, whether at home or hospital. We also know that more moms and babies suffer harm in the hospital, even if they fully recover.

So, if my baby is going to die, or suffer a problem of some sort, then I want to know that I did all I could, within nature's realm, to support a healthy pregnancy and birth...I would not want to experience a death or problem for myself or baby that was caused by medical practices. Even though the number of fatalities is about the same at home and in hospital--the amount of problems caused to mothers and babies at birth in the hospital, caused BY medical stuff (or for instance, virulent infections acquired only in hospitals), is far greater in the hospital. Therefore, I think on the whole that homebirth is safer for healthy moms and babies.
post #3 of 16
If you locate the full text of the various studies, they should have all that information. FWIW, I also think it's likely that some of the deaths probably are related to things that might have been more effectively dealt with in a hospital, like an abruption or such. However, there are deaths that occur in the hospital that would not have occured had the birth been at home. So for me, I made my decision based on which risks I was willing to take and which birth setting was most likely to result in the optimal outcome for a physiologically normal and healthy birth for me and my baby. And you can see in my sig what I chose for my second.
post #4 of 16
I sympathize with your thoughts here...that if we could design a perfect hospital that employs all the evidence-based practices we know foster natural labor (dark lighting, privacy, freedom of movement, ability to eat and drink, midwives only for low-risk women, hydrotherapy) and none of the interventions which we know increase risk without corresponding benefits (continuous fetal monitoring, mandatory IVs, etc), that would be the safest possible option. And I happen to know that in some places outside the US, that sort of care is available in limited places --- My first baby was born in a birth center in the UK which was in a hospital but was pretty much ideal and almost exactly like being at your own home, but had an operating theater down the hall. (the chances we could every have something like that here in America is basically nil because of the way healthcare is financed here)

But having had one "ideal" hospital birth and one homebirth, I can say that at least for me, I still think their are elements of safety you get from homebirth that you can't even get in an ideal hospital. For me, there was something about being in my own home...MY turf, where I felt safe and my brain could totally go to "labor land"...that made my labor go quick and easy for me and my baby. I did not need (and did not have access to) any sort of pain relief at home because I could be more relaxed and have a quicker labor, and that GREATLY reduced risk. I did not need to travel to the hospital, and we know well that the trip to the hospital and all the attendant stress very commonly stalls labor.

Like it or not, we are mammals and we evolved to labor under certain conditions, and I think for some women (though certainly not all) those conditions just cannot be replicated in any institutional environment.
post #5 of 16
Exactly. I think either scenario... where a baby dies BECAUSE it was born at home (and not correlational causes that would most likely have the same outcome at the hospital), and where a baby dies BECAUSE it was born at a hospital (due to unnecessary cesarean, or some virulent infection only found in a hospital) is equally rare and unlikely. But both are real risks.

I think it is pretty much going to be impossible to sort out which homebirth deaths are a result of being at home. There is a possibility that the baby would have had more immediate care at a hospital... if they are in a hospital with around-the-clock anesthesiologists and surgeons right at hand. But most hospitals do not have quite that capability, which is why so many of them are currently denying VBACs... If a hospital can not handle a VBAC emergency in an immediate time frame, it is not capable of handling any other birth-related emergency immediately, either. So, transferring from a home, time-wise, may end up being the same as the time it takes to get qualified staff there and get prepped, obviously depending on individual circumstances. So, who can really say how the outcome would be different? Most times there is simply no way to know for sure.

The main difference is that in our culture, if we are in a hospital, everyone will believe "everything that could be done was done" (even if the hospy IS the cause of the death), and at home it will be the parents' fault because they were irresponsible. So, there could potentially be a lot more serious emotional repercussions to the parents from outsiders upon losing a child during a homebirth. But is that potential emotional reaction from others in a VERY RARE instance, enough to sway you against avoiding the much more common and real risks of hospital interventions? It's not for me.

I think it is also important to look at maternal health outcomes. There are serious and lasting potential risks to c-sections for women, from reduced fertility to a 4 times greater death rate (still small, but much larger than the death rate for vaginal births). And when the c-section rate climbs above what is truly necessary, maternal death rates also sky-rocket (as we've seen in recent years here in the US).
post #6 of 16
I'm going off the top of my head - my articles are on another computer. I can check them out later and add in some information.

From what I recall, HB deaths in studies that list them fall into two categories. The first category are deaths that MAY or MAY not be preventable (meaning the underlying cause has a treatment - the question is whether or not the treatment would actually prevent the death in all cases of the cause). The second category are deaths due to un-treatable causes, such as severe congenital abnormalities where the baby would have died no matter what (lethal anomalies).

One thing to keep in mind is whether or not the study looks at planned HB or all out of hospital births. Including un-planned out-of-hospital births can raise the mortality (a horrible example are the awful stories of babies found in bathrooms and trashcans)

ETA: Ok, here's an example from an old Journal of the American Public Health Association from 1992 - they conducted a study of The Farm. I'm just listing a table the spelled out cause of death:

There were 17 deaths in 1707 births
Lethal Abnormalities: 6
Prematurity: 4
Death in utero: 2
Neonatal Sepsis 1
Abruption (during labor) 1
Respiratory Distress 1
Prolapsed Cord 1
Suspected Child Abuse 1

JAPHA Duran 82 (3): 450. (1992)
post #7 of 16
A major criticism of home birth has always been the potential of cord prolapse, which often requires expedient and emergency cesarean to save the baby. Interestingly, of the 9 cases of cord prolapse in the BMJ study, only 1 resulted in death. Of the 14 deaths recorded in that study, only 1 was due to cord prolapse. A flaw of the BMJ study is that it does not have a control group to compare outcomes to. If you look at the deaths in that study, it seems likely that most of those babies would have died regardless of birth place.

Here's a rundown of the fetal and neonatal deaths from the BMJ 2000 study:
Categories of intrapartum and postpartum deaths (n=14) among 5418 women intending at start of labour todeliver at home
Intrapartum deaths (n=5)
  • Term pregnancy, transferred in first stage, cord prolapse discovered with artificial rupture of membranes in hospital
  • Term pregnancy, breech transported in second stage because of decelerations, delivered during transport
  • Term pregnancy, breech, transport after birth at home
  • Term pregnancy, 41 weeks five days. Subgaleal, subdural,
    subarachnoid haemorrhage. No fetal heart irregularities detected
    with routine monitoring. Apgar scores 1 and 0
  • Post-term pregnancy at 42 weeks three days, nuchal cord 6X and
    a true knot
    Neonatal deaths (n=9)
    Lethal congenital anomalies (n = 3):
  • Dwarf and related anomalies
  • Acrocallosal syndrome
  • Trisomy 13
    Other causes (n = 6):
  • Term pregnancy, average labour. Apgar scores 6/2. Transported immediately, died at 1Y hours of age in hospital. Autopsy said “mild medial hypertrophy of the pulmonary arterioles which suggest possible persistent pulmonary hypertension of a newborn or persistent fetal circulation... some
    authorities would argue this is a SIDS and others disagree based on the age. Regardless, infant suffered hypoxia and cardiopulmonary arrest”
  • Term pregnancy, Apgar scores 9/10. Suddenly stopped breathing at 15 hours of age. Died at five days in hospital, sudden infant death syndrome
  • Term pregnancy, transport at first assessment because of decelerations, rupture of vasa previa before membranes ruptured, caesarean section, died in hospital two days after birth
  • Term pregnancy, Apgar scores 9/10. Baby died at 26 hours. Sudden infant death syndrome (SIDS)
  • Post-term pregnancy, 42 weeks two days age based on clinical data as mother not aware of last menstrual period and refused ultrasonography. One deceleration during second stage, which resolved with position change. Apgar scores 3/2. Brain damage associated with anoxia, baby died at 16 days
  • Term pregnancy. Mother and baby transported to hospital because mother, not baby, seemed ill, but both discharged within 24 hours. Mother, not baby, given antibiotics by physician a few days after the birth for general sickness. Baby readmitted from home at 16 days because of nursing problems, died at 19 days of previously undetected Group B streptococcus

The CMAJ 2009 (British Columbia) study does not cite the causes of perinatal or neonatal deaths in the study. However, it does cite very similar rates of perinatal death between home born and hospital born babies, suggesting that deaths occurring at home may not have been preventable if the birth site had been different.

The BJOG 2009 (Dutch) study also does not cite the causes of perinatal or neonatal deaths.

All very interesting food for thought!

Peace!
Laura Cochran, CPM
post #8 of 16
Quote:
Originally Posted by honeybee View Post
The main difference is that in our culture, if we are in a hospital, everyone will believe "everything that could be done was done" (even if the hospy IS the cause of the death), and at home it will be the parents' fault because they were irresponsible.


I couldn't have said it better myself!

When I look at the numbers in the home birth studies and see that the incidence of hemorrhage, retained placenta, manual removal, preeclampsia, exhaustion, malpresentation, postpartum infection, and severe tears are higher in the hospital born groups along with inteventions such as chemical augmentation, amniotomy, chemical pain relief, "assisted" (forceps/vacuum) delivery, and episiotomies that are higher in the hospital groups, it makes me wonder why people think a death in the hospital couldn't have been prevented, but a home birth related death could have.

Laura Cochran, CPM
post #9 of 16
And that one death to cord prolapse is because the OB at the hospital ruptured the mom's membranes. Probably well-intentioned, I'm sure, and trying to move along a labor that had been difficult enough to cause transport to the hospital, but it seems almost unfair to have that death included in the homebirth stats because it was caused directly by the actions of a hospital-based provider. I understand that is the way that the statistical analysis works -- that you keep people in groups even when their circumstances change.

When I look at the stats, I am shocked by the sids deaths. I would love to see more info about those cases and see if there were any other complicating factors.
post #10 of 16
From a personal standpoint, I feel that if I were to KNOW that the baby had a lethal congenital malformation, or I knew the baby was not going to live, I still would opt for homebirth. I would want the only moments of that baby's life to be loving, pleasant, calm, and secure. I would want to be with baby through birth and death. In a hospital, I DOUBT you would get the intimacy and privacy as you would at home. SO, in saying that, no, these deaths couldn't have been prevented, and if all these women with definite mortality outcomes chose to birth in the hospital, how much safer is homebirth? Much much safer if you ask me.
post #11 of 16
Quote:
Originally Posted by AustinMom View Post
From a personal standpoint, I feel that if I were to KNOW that the baby had a lethal congenital malformation, or I knew the baby was not going to live, I still would opt for homebirth.
I think this is a good point. For many people I homebirth could provide a preferable atmosphere for such a difficult event to take place.

However, for the purpose of these studies, it seems unlikely that babies with conditions diagnosed as incompatible with life before they were born would have been considered low-risk and included in the study. KWIM?
post #12 of 16
But the CPM 2000 study didn't exclude anyone from the planned homebirth group. If you were planning a homebirth with a CPM, you were included. They did remove the babies with the congenital anomalies from the deaths per thousand calculation. You're right, though, that those babies were likely not included in the hospital group.

It is part of homebirth culture, at least in my area, to have less genetic screening than the standard of care for hospital providers. So we probably are going to have more babies with chromosomal problems who are actually born at term instead of being aborted. If you just take a raw deaths per thousands calculation and don't remove the babies with the congenital anomalies, then you are probably going to get a higher rate of death at homebirths.
post #13 of 16
Quote:
Originally Posted by Defenestrator View Post
But the CPM 2000 study didn't exclude anyone from the planned homebirth group. If you were planning a homebirth with a CPM, you were included. They did remove the babies with the congenital anomalies from the deaths per thousand calculation. You're right, though, that those babies were likely not included in the hospital group.
Ooh, good point. I hadn't thought of that. And, unless other issues are presenting, there is no reason that a woman who doesn't know she's carrying a baby that's unlikely to survive would be considered high risk and excluded from the study.
post #14 of 16
also several of the home birth deaths were not what medicine would put in the low risk category
and I wanted to comment on this one
- --Term pregnancy, 41 weeks five days. Subgaleal, subdural,
subarachnoid haemorrhage. No fetal heart irregularities detected
with routine monitoring. Apgar scores 1 and 0--
is a very rare thing and is usually associated with use of a vacuum extractor that has been placed more than 1x the majority of the reports of this type of injury are from hospital births---
post #15 of 16
Quote:
Originally Posted by mwherbs View Post
...is a very rare thing and is usually associated with use of a vacuum extractor that has been placed more than 1x the majority of the reports of this type of injury are from hospital births---
Woah, scary true. I glossed over that and didn't put any more thought into it. Thanks for pointing that out.
post #16 of 16
Yes, thanks for mentioning that mwherbs. I wondered about that, seeing that cause of death.

Defenestrator--now I'm not sure about the births in the study mentioned, how causes of death were determined. But I do know in my state that autopsy is required on all babies who die between about 36wks gestation and 1yr of age (the ones who die prior to birth but 'at term', are considered in the SIDS group by all the articles I read in a study of IUFD I did 3yrs ago--not just in my state, btw). In any event, here, SIDS is only ruled as COD if all else has been ruled out via autopsy. So--child abuse, underlying physio/anatomical pathology (not necessarily visible on external observation), infection, etc, are ruled out as COD, via all that autopsy can do, before coming to SIDS as a COD.

And yes, many homebirth families here simply do not do u/s or other testing to discover anomalies prenatally; some do. But even those who do know in advance may be likely to choose homebirth if it is believed their child has fatal anomalies. They do prefer a peaceful birth and to aid in a loving passage of their baby, to the medical hype and useless med intervention.
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