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New study showing homebirth increases risk of nenonatal death. Thoughts? - Page 4

post #61 of 90
I've read the full study and posted my thoughts about it. (I'm not a professional statistician, but I am studying it at the graduate level.) There were 12 studies amounting to 342,056 homebirths. Most of those came from a recent large-scale Dutch study. A very large portion of the data, when you eliminate the large Dutch study, came from two outdated and/or badly designed studies -- rural western Australia in the 1980s, and birth certificates in Washington state. They also didn't include the north American midwife study.
They also used a very small portion of the data, just five percent, to break out that triple neonatal mortality rate. I believe that they did it this way because some studies expressed the mortality rate as perinatal deaths and some of the other studies expressed it as neonatal deaths. The Dutch study had 300,000 + homebirths, and the perinatal death rate in this study (which showed similar safety to hospital births) had 300,000+ homebirths it pulled from. The neonatal death rate came from just 15,000 births.
So I'm assuming -- and they never actually say which studies were used to generate the neonatal deaths, so this is just an assumption -- I'm assuming that they pulled the perinatal death rate from the Dutch study and a few others, and the neonatal death rate from the remainder of the studies. But we don't know which studies. The way they aggregated their data is exceptionally murky.
If it shows that births in rural Australia in the 1980s had a high neonatal mortality rate, I don't find that relevant to our current situation in the UK, Canada or most of the U.S.
Here's my thoughts on it: It is a tragedy when any baby dies, and it is especially a tragedy when a baby dies from malpractice, at home or in the hospital. I want American midwifery to be legalized, regulated and monitored, because I think that produces the best safety outcomes. I believe American midwifery could be safer, both in the states where it's not yet legislated, and in the states where it is legal. But I believe that overall, knowing that birth anywhere always carries risk, homebirth with a qualified provider, in a low risk pregnancy, and with systems in place in case of transfer, is relatively safe. I believe it carries a different set of risks than hospital birth.
I also believe that there are so many things that are deeply wrong and non-evidence based with the way babies are born in hospitals today. Mothers are put through a huge amount of unnecessary morbidity, injury and trauma because so many practices are not evidence based. I truly, in my heart, believe that the state of obstetrics in America today is a violation of human rights.
Would less babies die if we gave every single pregnant woman a C-section at 38 or 39 weeks? Possibly. You could make a case that doing that would actually reduce the total rate of infant mortality. However, you would wind up with a whole lot of other costs -- actual financial costs to taxpayers and insurers, as well as health costs to the mother, and emotional costs. Is it worth it to give 5,000 women unnecessary C-sections to save one baby? That's the way that you have to think about it if you're looking at it from a true public health perspective.
post #62 of 90
Quote:
Originally Posted by *MamaJen* View Post
Here's my thoughts on it: It is a tragedy when any baby dies, and it is especially a tragedy when a baby dies from malpractice, at home or in the hospital. I want American midwifery to be legalized, regulated and monitored, because I think that produces the best safety outcomes. I believe American midwifery could be safer, both in the states where it's not yet legislated, and in the states where it is legal. But I believe that overall, knowing that birth anywhere always carries risk, homebirth with a qualified provider, in a low risk pregnancy, and with systems in place in case of transfer, is relatively safe. I believe it carries a different set of risks than hospital birth.
re: the bold. Does that mean you also support forcing high-risk women into hospital-based care with an OB? That seems to a sentiments that's popping up here a lot, and I want to make sure I'm reading it right.

The only thing that made me high-risk was the fact that an OB cut me open, after I'd said "no" when I was 24 years old. That was it. I've never had a single health problem during pregnancy - not once, not ever. Even the death of Aaron was more complicated than it would look in studies (contributing factors included the fact that my labour stalled when CPS* intake worker showed up at my front door while I was naked in a birth pool in my living room). So, because I'd been...well, basically assaulted...by an OB once, I should have no legal choices, except to subject myself to that again, or not have any more kids?

I'm just trying to clarify if we're really saying that we want to protect women, babies and midwives, by forcing certain women into hospitals, because that's what it sounds like.



*They're not called CPS here, but I don't know the current name of the agency and I figure everyone here understands "CPS".
post #63 of 90
Quote:
Originally Posted by Storm Bride View Post
re: the bold. Does that mean you also support forcing high-risk women into hospital-based care with an OB? That seems to a sentiments that's popping up here a lot, and I want to make sure I'm reading it right.
Absolutely not. I believe in a woman's determination over her own body. But things like twins, breech, high blood pressure, HBAC/VBAC etc add additional risk to homebirth. I passionately believe in the concept of informed consent. I think women deserve to have an accurate assessment of those risks, and make their own decision. And of course, a midwife would choose or not choose to attend that birth.
The problem is that I really don't think we have clear information on what that risk is. Is it one in a hundred? One in a thousand? One in ten thousand? It's hard to do risk assessment when you don't have good information. 100 percent chance of a C-section in the hospital, with all the related risks or a ...what? chance of a bad outcome at home.
If I was carrying twins or a breech baby or something similar, I would spend a long time on the decision making process, and honestly I don't know which birth setting I would wind up choosing, but I would still want to have the right to make that decision.
I know the state does things to legislate safety. We have to wear seatbelts, only surgeons can perform surgery, etc. Depending on the level of risk, I think reasonable people could disagree on whether or not midwifes should be prohibited from attending "high risk births" (and just defining that would be a huge effort.) I personally don't think midwives should be prohibited from, say, delivering a breech baby, though there are reasonable arguments to be made for the other side.
post #64 of 90
Quote:
Originally Posted by Storm Bride View Post
Punching some stuff into a database sounds good...but I'd want to see some really serious measures in place to ensure accuracy.
I agree. Even if it were doable I don't think it's ever going to be truly accurate... and if it's not truly accurate then what is the point?

I have the long form birth certificate for my oldest son. It lists the "details" of birth. Here we fill out the form ourselves, and I did it online and I'm 100% sure that *I* didn't make any mistakes as I still have the print out confirmation. There is also the same information sent in by the care provider.

The doctor listed on his form as the delivering attendant I never even met. It is quite possible that it was one of the OBs on call that day, but I have the names written down of the attending OB, the resident who actually caught him, plus my own midwife and none of those people is on the birth certificate as the delivering attendant. So if we were doing statistics by care provider my statistics for his birth (vaginal, no episiotomy or tearing, healthy baby with good APGARs, no forceps etc etc) would be going under someone who was definitely not even in the room.

Plus his gestational length was wrong. He was born at 43 weeks, 2 days. It *is* possible that I ovulated a day or even a couple of days later as I wasn't tracking that. But there was *one* experience where I could've gotten pregnant. We're talking months before that if it wasn't then. And after he was born before I could've gotten pregnant after that one time. But his birth certificate says 40 weeks, 3 days. Why does it say that? Because a (non first trimester) ultrasound said I couldn't possibly be as far along as I was. Despite the fact that I was a sexual assault survivor who was not partnered. I'm not guessing what lead to his conception. And yet I had an OB look me in the eye and say "Sometimes women are wrong about these things, you just don't understand." And my hospital records say that "Patient presented thinking she was 43 weeks but she was wrong about her dates and they were adjusted to reflect 40 weeks". (not that exact wording but you get the point)

I have no confidence that you can get truly accurate statistics for stuff like this. There are just too many variables involved I think.

ETA: I meant to also say that he was a 43 weeker who was healthy. No breathing problems, APGARS were 8/9/9. Strong all through labour. There *are* risks to going to 43 weeks. But he is an example of a baby who was fine. Better than fine even. But he's not included in the statistics for truly postdates babies as a success because an OB that believes in an inexact science (ultrasound) above all else.
post #65 of 90
Oh, yeah. I've mentioned this before, but I want to stress again that this study showed a 9.3 percent C-section rate.
In America nowadays, it's what, 32.5 percent?
I think that's just another indication of how this study doesn't portray our current reality.
post #66 of 90
Quote:
Originally Posted by *MamaJen* View Post
Oh, yeah. I've mentioned this before, but I want to stress again that this study showed a 9.3 percent C-section rate.
In America nowadays, it's what, 32.5 percent?
I think that's just another indication of how this study doesn't portray our current reality.
Exactly. And here it's at over 39% just at the local hospital. I just want to give a big to you, Jen. This study is seriously flawed in every way. And everyone keeps concentrating on homebirth mortality but ignoring the tripling of neonatal and maternal death rates from c-sections which happen in hospital and the many many deaths and complications from hospital births. My son was one of those (he luckily lived, but no thanks to the hospital which made the complications). Everything has risks in life-I just wish that American midwives were covered by insurance, regulated and certified, and made more available for women both in hospital and in home.

Storm Bride, I agree with you, too. I did not have a c-section, though they tried their hardest to force me-thank the gods for parents who threaten litigation when you're too exhausted to think and surgeons who are decent human beings and not the "cut em open no matter what" type. But since I had a myomectomy, I have had to fight literally tooth and nail for a decade now because of our screwed up system. I've been mistreated, assaulted during birth even after refusing things...for me the only safe place,except for arising complications, obviously, is out of hospital. Because I know what it's like to be treated less than human otherwise.
post #67 of 90
Quote:
Originally Posted by *MamaJen* View Post
Absolutely not. I believe in a woman's determination over her own body. But things like twins, breech, high blood pressure, HBAC/VBAC etc add additional risk to homebirth. I passionately believe in the concept of informed consent. I think women deserve to have an accurate assessment of those risks, and make their own decision. And of course, a midwife would choose or not choose to attend that birth.
The problem is that I really don't think we have clear information on what that risk is. Is it one in a hundred? One in a thousand? One in ten thousand? It's hard to do risk assessment when you don't have good information. 100 percent chance of a C-section in the hospital, with all the related risks or a ...what? chance of a bad outcome at home.
If I was carrying twins or a breech baby or something similar, I would spend a long time on the decision making process, and honestly I don't know which birth setting I would wind up choosing, but I would still want to have the right to make that decision.
Okay. Fair enough. The mantra of "low risk" women is just getting to me a bit.

Quote:
I know the state does things to legislate safety. We have to wear seatbelts, only surgeons can perform surgery, etc. Depending on the level of risk, I think reasonable people could disagree on whether or not midwifes should be prohibited from attending "high risk births" (and just defining that would be a huge effort.) I personally don't think midwives should be prohibited from, say, delivering a breech baby, though there are reasonable arguments to be made for the other side.
I'm not actually a big fan of legislation for one's own safety (eg. seatbelts) as opposed to legislation to protect third parties (eg. having to prove you can do surgery before you're allowed to do surgery).

In the case of birth, it's even more complicated than that, because defining risk is really slippery. I know that coping with doctors caused me a huge amount of prenatal stress. I actually put off seeing the GP about an OB referral with dd2 for months, because I just couldn't face it...and that was knowing that I was going to have a c-section in the end. Every visit was just a huge ball of stress. (You know...the only high blood pressure reading I've ever had during a pregnancy was while the GP was talking about how she would "manage" my labour when I was intending to VBA2C. The doctor commented herself that my bp was high, while talking about this, and took a new reading - it was normal - at the end of the visit, because of that. If just talking about all the restrictions and "requirements" could affect my blood pressure, what would the actual experience have done for me??)

The "pure numbers" approach to all this really worries me. I know we need quantifiable data, but...it's only part of the picture. The impact on quality of life (for both moms and babies) gets lost in the shuffle when we focus on the numbers.

I don't want any of my children to ever lose a baby. I truly wouldn't wish that experience on my worst enemy. But...I also don't want my girls to go through what I went through in my pregnancies prior to that. And, according to the numbers, I went through four near-perfect "births"...healthy mom (hahahaha - but we're not talking about reality - we're talking about what's on paper or in a computer), healthy babies, great apgars, good recoveries - you name it. They were perfect...and I wouldn't wish them on anyone, either. Someone looking at the numbers wouldn't see a problem at all.
post #68 of 90
subbing to come back later and read
post #69 of 90
Thread Starter 
Quote:
It is a tragedy when any baby dies, and it is especially a tragedy when a baby dies from malpractice, at home or in the hospital. I want American midwifery to be legalized, regulated and monitored, because I think that produces the best safety outcomes. I believe American midwifery could be safer, both in the states where it's not yet legislated, and in the states where it is legal. But I believe that overall, knowing that birth anywhere always carries risk, homebirth with a qualified provider, in a low risk pregnancy, and with systems in place in case of transfer, is relatively safe. I believe it carries a different set of risks than hospital birth.
I also believe that there are so many things that are deeply wrong and non-evidence based with the way babies are born in hospitals today. Mothers are put through a huge amount of unnecessary morbidity, injury and trauma because so many practices are not evidence based. I truly, in my heart, believe that the state of obstetrics in America today is a violation of human rights.
I wish I could put this in my sig! ITTTTTA. Great post.
post #70 of 90
Quote:
Originally Posted by bicyclingbethany View Post
Angela- Just FYI, CPMS can and do cut episiotomies here in Texas. I had one!

PP whose name I don't remember- Texas has released data more recent than 2004, and I posted the link to 2007 primary c/s data in my previous post.

Well, I guess we can all agree from this- no one is crunching enough numbers and no one is being transparent enough!
Fascinating! Last I read the regulations they were specifically forbidden from cutting episiotomies as they were considered surgery. When I read up on it they were actually forbidden basically from cutting anything but the cord. But it has been a few years since I read up on it.

And the problem is that now the only TX data being released is info that can't be used to extrapolate full C-section stats nor can it be compared with previous information

-Angela
post #71 of 90
Quote:
Originally Posted by bailefeliz View Post
Data (fetal death certificates, essential to assess outcome) from Oregon DHS, Vital Stats, is entirely flawed because of data input errors by the admission of the Director or DHS.
I'm not sure I understand this sentence. So your Pubic Health Division is admitting to inputting flawed data?

Quote:
Originally Posted by bailefeliz View Post
Again, currently, at least in my State, there is no data on LDM/CPM/DEM outcomes. There is a high suspicion that rates are unacceptably high for perinatal death within OoH birth management.
All that I can find for your state's birth outcomes, as referenced in a post above, is whether women had cesarean or vaginal births....basically the same data that you provided earlier. So it isn't fair to say that there are "no data on LDM/CPM/DEM outcomes" because the data does account for planned home births and freestanding birth centers (the latter named by facility). So it looks like docs and mw's are getting pretty equal treatment.

I could find no facility-wide data for neonatal mortality, not for hospitals or OOH midwives. If you could link me to some that would be great. Otherwise, with regard to neonatal mortality rates with OOH midwives, "speculation" might be a better word than "suspicion." Forgive me for belaboring this topic, but I'm just not seeing how there's less transparency for OOH mw's than there is for in in-hospital maternity care providers.

I do agree with you that complaint-filing should become an easier process.
post #72 of 90
Storm Bride,

You are absolutely right about records being a mess. Mine are seriously off. My doula took notes and when you compare her notes to my medical records, none of it makes sense. So, either the nurse was lying (possible) or doing a poor job with her data. In my mind, either one should be against the law in my opinion.

For example, my little c-section baby was also diagnosed as having shoulder dystocia. That really makes no sense (the baby is either in or partially out - and to put the baby back in is pretty risky). Or they seriously screwed up. I will never know.

Yes, it takes more effort and time to have accurate records. I worked for a medical device company and the cost and time we had to spend to accurately record every little thing was mind boggling. And yet, the place where our products were used are held to much less of a standard.

Maybe things will be better for my children. I certainly hope so!
post #73 of 90
Quote:
Originally Posted by *MamaJen* View Post
Oh, yeah. I've mentioned this before, but I want to stress again that this study showed a 9.3 percent C-section rate.
In America nowadays, it's what, 32.5 percent?
I think that's just another indication of how this study doesn't portray our current reality.
I think this is really important to see. We are kind of running off in many different directions in these two posts about this topic instead of really discussing the actual meta analysis.

I appreciate everything you have posted MamaJen!
post #74 of 90
I agree it was a relief to read *MamaJen*'s posts before I was able to get my hands on the article and I could not put it better than she has after reading it-
thanks for all the work-
post #75 of 90
Quote:
Originally Posted by MidwifeErika View Post
I think this is really important to see. We are kind of running off in many different directions in these two posts about this topic instead of really discussing the actual meta analysis.

I appreciate everything you have posted MamaJen!
But it does make sense when you take into account that they took all the high-risk pregnancies out of both groups.

I don't know. I am not impressed by the meta-analysis, but the homebirth community's immediate dismissal doesn't make me any more comfortable about evidence-based medicine on either side.
post #76 of 90
I just went to the CDC website and looked up all infant births/deaths for 2003-2005 (the most current available), sorted by medical attendant and birthplace..
http://wonder.cdc.gov/lbd.html1 (such a huge amount of information available there, and you can group it in dozens of different ways)
MDs in hospital showed a death rate of 7.15 per thousand (OB's are lumped in with MDs, AFAIK)
CNMs in hospital: 2.88 per thousand
CNMs out of hospital: 2.70 per thousand
"Other Midwifes" out of hospital: 3.84 per thousand

The highest death rate shown, oddly enough (not counting the "unknown/not stated" category), is MDs out of hospital, at 29.36 per thousand.
post #77 of 90
Quote:
Originally Posted by laughingfox View Post
I just went to the CDC website and looked up all infant births/deaths for 2003-2005 (the most current available), sorted by medical attendant and birthplace..
http://wonder.cdc.gov/lbd.html1 (such a huge amount of information available there, and you can group it in dozens of different ways)
MDs in hospital showed a death rate of 7.15 per thousand (OB's are lumped in with MDs, AFAIK)
CNMs in hospital: 2.88 per thousand
CNMs out of hospital: 2.70 per thousand
"Other Midwifes" out of hospital: 3.84 per thousand

The highest death rate shown, oddly enough (not counting the "unknown/not stated" category), is MDs out of hospital, at 29.36 per thousand.
No, that makes perfect sense - MD's out of hospital would mostly be unplanned, emergency type births, not excluding high risk mothers and without any equipment to help a lot of the time. Hurricanes, planes, black outs, etc.
post #78 of 90
Laughingfox-

What search criteria did you use?

ETA: If you don't change the criteria, then you choose babies who died 20 weeks or less gestation to 364 days old. These extremes obviously have little if nothing to do with the birth attendant.

Try babies 37+ wks gestation to 23 hours old and see what you get.
post #79 of 90
Quote:
Originally Posted by laughingfox View Post
I just went to the CDC website and looked up all infant births/deaths for 2003-2005 (the most current available), sorted by medical attendant and birthplace..
http://wonder.cdc.gov/lbd.html1 (such a huge amount of information available there, and you can group it in dozens of different ways)
MDs in hospital showed a death rate of 7.15 per thousand (OB's are lumped in with MDs, AFAIK)
CNMs in hospital: 2.88 per thousand
CNMs out of hospital: 2.70 per thousand
"Other Midwifes" out of hospital: 3.84 per thousand

The highest death rate shown, oddly enough (not counting the "unknown/not stated" category), is MDs out of hospital, at 29.36 per thousand.
those rates don't shock anyone else?
Lay midwives have a much higher rate of death than CNMs in or out of the hospital. of course obs have the highest rate they are the ones with all the high risk patients, all the preterm babies, all the no prenatal care-show up to deliver mamas. but obviously- from these numbers- lay midwives are NOT as safe as they could be-
its the difference of getting a masters degree (cnms) or doing a modular based training and observing 100 births (texas standards).
post #80 of 90
Quote:
Originally Posted by GuildJenn View Post
I don't know. I am not impressed by the meta-analysis, but the homebirth community's immediate dismissal doesn't make me any more comfortable about evidence-based medicine on either side.
Agreed.
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