Is there a study that looks only at CNMs?

[carriebft]

Does a homebirth study exist that examines only CNM attended homebirths and outcomes in comparison to hospital?

Particularly I am looking for one based in the US. I was told the recent netherlands study would be good because the training their midwives and CNMs is similar (that CNMs here are the closest comparison) but I was wondering if there was anything like that published with US data?

[lunita1]

Originally Posted by carriebft

Does a homebirth study exist that examines only CNM attended homebirths and outcomes in comparison to hospital?

Particularly I am looking for one based in the US. I was told the recent netherlands study would be good because the training their midwives and CNMs is similar (that CNMs here are the closest comparison) but I was wondering if there was anything like that published with US data?

If there were anything, I think it would be very difficult to draw any useful conclusions from it. The sample size would be too small. There just aren't very many midwife-attended homebirths in the U.S. period, and the number of CNM-attended births is a small fraction of those. Most CNM's work in hospitals and birth centers.

In my own community, it makes more sense to look at the individual caregivers and weigh what I know about their training and level of experience. Do I want a CNM with only a few years of experience and not very many births under her belt, or a direct-entry midwife who has been attending births for almost 30 years? Also meet them and get to know their personalities, their policies and their ways of dealing with crises. I think that's more likely to tell you about the relevant risks in your situation than a collection of data from all of the CNM-attended births in the US.

[carriebft]

I was actually wondering just for "ammo" against recent homebirth studies that do not differentiate between kinds of midwives. Some family members have been sending me the newest homebirth study today that tries to claim neonatal deaths from homebirth are 3x higher-- and most of those deaths come from resuscitation issues I guess. But it seems that no difference is made between kind of midwife (or any midwife at all). I was telling my aunt that this study does not accurately represent my birth choices, so I wondered if there was a study out there that did, kwim?

[loveneverfails]

I vaguely remember seeing a study that did compare OB in hospital, CNM in hospital, CNM at home and "other midwife" at home. I don't know where it is anymore, but I know I saw one at some point.

And my comfort level is higher with CNMs in a home birth situation *in general* but there are absolutely some CPMs that I'd trust over some CNMs. It really depends on the midwifery training and what you personally find important. It's important to me at this point to have a midwife who has worked with higher risk cases in the hospital, so my midwife who has done high risk OB in the hospital was a very good choice for me. I don't think that's an absolute requirement in the abstract, but having encountered more issues than average in my births, I feel safer with a midwife with more experience in "weird stuff."

[AlexisT]

I would stick to criticizing that particular study. It's a meta-analysis based on studies from multiple countries. In some cases the data is old or incomplete (some of the studies relied on birth certificates) or the samples were small. It's simply poorly done.

[*MamaJen*]

Originally Posted by carriebft

I was actually wondering just for "ammo" against recent homebirth studies that do not differentiate between kinds of midwives. Some family members have been sending me the newest homebirth study today that tries to claim neonatal deaths from homebirth are 3x higher-- and most of those deaths come from resuscitation issues I guess. But it seems that no difference is made between kind of midwife (or any midwife at all). I was telling my aunt that this study does not accurately represent my birth choices, so I wondered if there was a study out there that did, kwim?

Oh, are you talking about that Australian study? It's totally not relevant to the U.S. Did it even differentiate between assisted and unassisted births? It also included all kinds of high risk pregnancies in there, and when you looked at the deaths there wound up being maybe two that were low risk and preventable -- and in those cases you didn't even know if they were taking place unassisted in the outback 1,000 miles from a hospital.
Here's a good breakdown of it: http://hoydenabouttown.com/20100116....uth-australia/

I think that Canadian study may have included CNMs, but if I recall correctly, it was looking at them in a hospital setting. The most interesting element of that research, to me, was the fact that the CNMs practicing in hospitals used rates of interventions nearly as high as the physicians.

So my thought on it is this: Is homebirth in the US as safe as homebirth in Canada or the Netherlands? Probably not across the board, since so many states don't regulate it or outlaw it all together, and many areas don't have good systems in place in case of transport. And while I think that some lay midwives have wonderful training and safety records, others don't.
Now, in states that regulate CPMs, and you're in a relatively urban area close to a hospital, and you're low risk, and you've researched to see if your midwife has strong experience and a good safety record, in that case, I think it's as safe as homebirth gets.

[*MamaJen*]

Oh, just saw the reports about the new study. It'll be interesting to read the full study and see how they compiled the numbers.

[Romana]

Not in the U.S., as far as I am aware. The closest I've seen is some work of people using the raw CDC numbers to try to draw a few conclusions about CPM or DEM vs. CNM, since that data differentiates between those categories. The results show a strong differential in safety between the two. It's pretty stark. CNMs look good for both hospital and homebirth, though (generally speaking).

MANA has data. I think they have a duty to publish it, but of course they aren't at the moment, which doesn't inspire confidence.

[AlexisT]

MamaJen, I think she's talking about a meta-analysis that was just published in AJOG. (News item: http://www.guardian.co.uk/lifeandsty...h-babies-study) Which, as I said above, is problematic. You can't mush together studies from the US, Netherlands, Canada, UK, Sweden and Australia! It simply doesn't control for differences in the countries' maternity systems.

I am not a fan of using raw CDC numbers. There's a reason serious studies do real stats collection.

The Canadian studies did look at home birth--there was a large one in Ontario published a year or two ago. Canadian RMs are not required to be nurses. However, new entrants are trained in university based courses, can handle home or hospital births, have hospital privileges, and have required levels of consultation with physicians. Similarly, the Dutch system also has very high levels of caution (the news reports about the study said there was a transfer rate of 30%, and I know there are a ton of rules about having an HB there--midwife must be no more than 20 mins away, minimum distance to hospital, no breeches, no multiples, no VBACs) and has a well developed infrastructure and transfer system. So I'm also wary of generalizing from foreign studies. I gave birth outside the US and the system is just so different; I don't see how you could use statistics from home birth in one place to prove anything about the other.

[*MamaJen*]

Okay, I just got a hold of the new study and had a quick read over it -- it's pretty much what you'd expect. As a meta-analysis, it's only as good as the studies it's based on. I was surprised by how old a lot of the data was -- I don't think homebirths in California from 1976 - 1982 are relevant to homebirths in Austin in 2010. It looked like by far the bulk of the numbers came from a study in the Netherlands published last year, based on data collected between 2000 - 2006. Has anyone seen that study? I'm not even familiar with it. I also noticed they appeared to leave out the North American Homebirth study, which showed similar mortality rates.
Anyway, I'll be interested in reading a deeper breakdown of the study. I'm sure Henci Goer will be on it pretty quickly.

[AlexisT]

The Dutch study was discussed here before, and got a lot of press. As far as I can tell, it was a large, well done, reputable study. The usual anti-home birth suspects didn't attack its authors or methodology. Their arguments against it were, basically, "the Netherlands is not the US." Which is true enough, and as I said above, I'm leery of generalizing from foreign studies. But it did seem to show that home birth is not conceptually unsafe.

[*MamaJen*]

So looking at this meta-analysis a little more closely, what I wanted to see, and didn't, was where the deaths came from. The paper gives mortality numbers, but doesn't include a breakdown to show which deaths came from which studies.
Also, you know what's pretty hilarious? It shows a 9.3 percent Cesarean rate in the planned hospital births. Where the hell that number came from, I have no idea, but it's not from here and now.

They looked at 342,056 planned homebirths, of which 321,307 came from the Dutch study.

ETA:
So basically, the bottom line in this study is they're showing a perinatal death rate of .07 for homebirths (229/331,666) vs. a .08 percent death rate for hospital births (140/175,443). Then they're showing a neonatal death rate of .2 percent (31/16,500) for homebirth, versus .09 for hospital (31/33,302).
That "three times as deadly" number comes from they're findings of nonanomalous noenatal death, where they're showing .15 percent (23/15,633) for homebirth, vs. .04 (14/31,999) for hospitals.

So basically, what that means to me is they were primarily using the Dutch study to find that perinatal death rate, which shows very similar mortality at home and in hospital. Then I guess that triple neonatal death rate was pulled from the other studies.

[fruitfulmomma]

tries to claim neonatal deaths from homebirth are 3x higher

I don't remember the specifics, but I know she-who-must-not-be-named was throwing this around for awhile and when I read the study I came to the conclusion that the "3x" was statistically insignificant. It was phrased as "3x" in order to make it look scary. But 1 in 1000 vs. 3 in 1000 could easily be explained by errors and not taking into account other information. And even if it could not, I am still comfortable enough with my choice as being statistically safe.

Either way, I agree with checking out your *own* midwife. My is a direct-entry midwife because that was the only way she could practice legally when our laws changed here. But before that she was an L&D Nurse for many years.