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Thoughts on "planned home births are associated with double to triple the risk of infant death...

post #1 of 394
Thread Starter 

I have had a homebirth with my second and absolutely loved it.  My CPM was great and I delivered fast.  My 3rd was delivered in the hospital again for insurance purposes and I butted heads with all the hospital staff there when I showed up to deliver (I showed up an hour and a half before delivering).  You just can't act as free in the hospital even when they try to meet your demands.  I could tell it was hard for them to have me there and it was hard for me to be there.  One nurse who was quite angry with me while laboring came up to me after delivery and apologized for her behavior and said she was afraid if she helped me that she would lose her license because she was certain things would go wrong because I didn't have the EFM continuously, didn't take the I.V., etc (mind you all this was agreed to by the midwife and in my chart before my arrival to deliver).  I am looking at a homebirth this time again for the freedom but I do want the best care for my baby and me even if it means I have to fight the hospital during labor.  After doing some reading about the Colorado and California stats I am quite concerned that perhaps I am more in love with conveniences for me rather than safety for my baby.  What are your thoughts?  Any research would be greatly appreciated both pro and con.

post #2 of 394
http://www.ajog.org/article/S0002-9378(10)00671-X/fulltext

This is an interesting look at homebirth v. Hospital birth. It's a collection and analysis of a lot of studies. ACOG has asked practitioners not to participate in studies involving planned homebirth due to their stance against it so that makes data collection harder now I think. I think it is interesting that you had "demands" at the hospital, "requests" may make the situation easier on everyone, semantics are important. Homebirth can be very safe with a good practitioner and the mother's acknowledgement of what situations call for transfer. I believe what makes homebirth unsafe is a lack of standardization of what qualifies a good midwife. Homebirth clients and/or midwives also get into trouble because of willingness to transfer, some may not know what requires a transfer of care (i have seen this myself). Hospitals need to do their part to be better (also stated in ACOGs stance on homebirth) and only intervene when necessary. The truth is though that there are risks involved in both settings. It will be awhile before midwives have better standardization and hospitals stop medicalyzing every birth. It is every mothers decision to weigh the risks and make the best decision she can.
post #3 of 394

Google CDC Wonder database on neonatal mortality by practitioner.. It has instructions .

 

Numbers speak for themselves.

post #4 of 394

The headline "double to triple the risk..." was a sensational one put out there by ACOG to turn women away from homebirth and it probably did just that because it is human nature to read just the headlines and ignore the rest.  Among those of us in the childbirth field we know this "research" as  the Wax study named for the doctor who did the study.  Included in the study were unplanned home births like very premature babies born to women who didn't know they were in labor and other unplanned home births.  Us midwives finish the sensational headline by saying "double to triple the risk if the baby is born premature and without a trained birth attendant..."  If you plan on having your baby at home with a trained attendant and not premature, you shouldn't have the worry about safety.  All that being said, there isn't good research about home birth "safety" in the US.  Studies done in other countries that have better training for home birth midwives (like Canada and Sweden) show home birth to be very safe and in many ways better than a hospital birth.

post #5 of 394

Home can be a wonderful place to have a baby, but it is the midwife who makes it safe.

I am involved in research involving midwifery education and standards around the world. The UNFPA report (State of the World Midwifery) is excellent for understanding how our standards in the US differ from the  rest of the world.

 

CNMs in the US have education and training that is on par and equivalent to midwives throughout Europe. Almost every European country requires that the midwife first be a nurse and then complete a university based midwifery program. There are some small variations, but that is the standard. There are countries in Europe where midwives handle the majority of births in that country but those births also take place in hospital. So to expect that all midwives are doing home birth and getting excellent results is not true. In most European countries the home birth rate is less than 2 %, except for the Netherlands. However, in the Netherlands women are able to choose home birth only if they live within 15 minutes of the hospital, and midwives are limited in the number of birthing women they have in their caseload. In all European countries the midwives are licensed and regulated. They may only take care of women who have no risk factors such as elevated blood pressure, twins, breeches, diabetes, etc. Any woman who develops complications such as prolonged rupture of membranes, prolonged labor, bleeding, etc. must be immediately transferred to hospital. The midwife may continue care there, she may consult with the physician, or she may transfer care to the physician. If she fails to provide competent care in this way there will be an investigation and she may be censured. Midwives in Europe are much more integrated into the medical system. Most midwives are also required to carry liability insurance. All of the reasons listed above are why midwives in Europe can say that home birth is safe and why they have the statistics to back that up.

 

CPMs in the US must have a minimum of a high school education. Not a university education like most midwives in the rest of the world. They may or may not have attended an accredited midwifery program. And may or may not  be licensed in their state. The laws regulating midwives in your state may be quite stringent or lax. They vary by state. The board that regulates midwives in your state may or may not make disciplinary actions public. If they don't then you have no way of knowing whether there have been complaints against that midwife and if she has been asked to take corrective actions. In some states the citizens maintain a database of complaints and discipline (Oregon) so the public is a bit more informed. Some CPMs may have a good relationship with a physician and will refer for an opinion or additional care and testing when risk factors appear. Others consider those risk factors a "variation of normal" and will not consult. This can be dangerous. Remember that in countries where  midwives are educated, licensed and regulated , risk factors or complications require consult, referral, and transfer to the hospital. In the US with CPMs and especially with non-certified midwives there is no system in place to be sure the mother is transferred to a more appropriate level of care and usually there are no repercussions when the mother or baby are harmed or die. Most non-nurse midwives do not carry liability insurance. This means that if the parents want to sue to recover damages or to pay for ongoing medical care for the baby who has permanent damage, that the parents won't have a way to make the midwife accountable for her actions. 

 

Non-certified midwives(DEM, community midwife, practical midwife, etc.) have no minimum educational requirement, not even a high school diploma. They are not required to study the basic sciences like anatomy and physiology and usually learn their trade through apprenticeship models. If the midwife they learn with doesn't know and understand these things, they may not either. They usually have little to no access to medications for postpartum hemorrhage and if they are illegal in your state they will not want to transfer you to the hospital when it is necessary or lifesaving, and if they do, they may not accompany you which means the hospital staff has no idea what has happened to that point, and it causes serious delays and disruptions in the care your receive. This makes the situation more life threatening.

 

One of the UNFPA's reports about midwifery says "Giving Birth Should Not be a Matter of Life or Death."  Without knowing the qualifications, education, and competency of the midwife you may choose, home birth in the US may not be as safe as we would like to think.


Edited by mothercat - 2/24/13 at 7:21am
post #6 of 394

The best OOH birth outcomes result from attendance by a trained and skilled midwife who collaborates with physicians and medical facilities and has clear risk-out criteria for eligibility for home birth. Unfortunately we do not have an ideal system for assuring this type of safety and high-quality care in the US. Even licensed midwives can have difficulty assuring smooth referral or transfer of care to the hospital or collaboration with physicians when needed. I've found that unlicensed midwives have an even harder time assuring these safety measures.

 

I think it is wise to be cautious. This is your baby, and your body, and the health and well-being of both of you. I don't believe that homebirth is safer than hospital birth - as midwives often say. I just don't. I believe that low-risk mothers experiencing healthy pregnancies with no discernable risk factors attended by a licensed certified midwife who practices in accordance with safe standards of care can provide care that is pretty darn good - and probably comparable to hospital birth. But removing any of these factors (risk-out criteria, practice standards, qualified midwife), the outcomes will be poorer.

post #7 of 394

I like this video:

 

post #8 of 394

I really like Dr. DeClerq. He is thoughtful and very well spoken, a brilliant academic. However, the central issue remains the knowledge, experience, skills, and education of the home birth provider.  Home birth is safe when the woman is having an uncomplicated  pregnancy and you have a midwife who understands that any deviation from that requires consultation and possibly transfer to another provider at the hospital. That is the critical piece of safety.

 

BTW: I am a home birth midwife and have had a home birth myself.

post #9 of 394

There have not been any apples-to-apples comparisons (with matched socioeconomic and risk profiles) between home birth mothers and hospital birth mothers in the U.S.  I think the "double to triple the risk" estimate is a bit high--double would probably be more accurate.

 

Relative risk does matter--a risk that is doubled is a significant risk, especially from a population/public health standpoint.  But absolute risk also matters:  doubling a low risk can still give you a low risk.  The risk of neonatal death from homebirth, assuming a competent midwife and nothing too far out of the bounds of accepted practice, is just about equal to the risk of miscarriage from an amniocentesis (approximately 1 in 300 to 1 in 500).  Yet amnios are medically regarded as mostly safe, and are widely recommended, while homebirths are denounced as crazy and dangerous.

 

You could also flip the analysis around, and say that hospital birth only decreases the neonatal death rate by 50%.  So hospital birth is not a guarantee of total safety, either.

 

Also, hospital birth carries a very high risk of c-section, which creates new risks for subsequent pregnancies.  Some of those lives saved in the hospital are coming at the expense of later babies, but it's not something that can be dramatically quantified in a statistic.

 

 

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post #10 of 394

Vaske, I'm a little unclear whether you are comparing homebirth to all hospital births or only low risk hospital births? 

 

In any event, I think one point that must be taken into account in comparing the death rate of these two birth methods is the TYPE of infants that are dying in homebirth versus hospital birth.

 

My understanding is prematurity and birth defect are the two of the largest causes of neonatal hospital death.  Aren't those babies in dying in homebirths more commonly term, "normal" infants?   And doesn't that make the larger rate of death at homebirth you note even more concerning?

post #11 of 394

"Aren't those babies in dying in homebirths more commonly term, "normal" infants?"

 

The deaths have I've read about have been breech babies.

post #12 of 394

The comparison was of homebirths to low-risk hospital births, but many homebirths would not be medically considered low-risk (VBAC, advanced maternal age, etc.).  Comparing low-risk hospital births to low-risk homebirths would likely show that homebirth is statistically about as safe as hospital birth.  The numbers that I looked at a few years ago excluded birth defects from both.  Many homebirth parents skip prenatal testing and ultrasounds (and selective terminations), so probably have more birth defects that aren't detected until birth, while hospital births where birth defects are detected are not considered low-risk.  No one has compared prematurity rates that I know of, but considering the socioeconomics--homebirthers tend to be older, whiter, better educated, more affluent, more health-conscious and less likely to smoke, drink alcohol or abuse drugs than those who hospital birth--probably homebirth has a lower risk of that as well, but I don't see it as being strongly related to the planned place of birth.

 

If you want more details, much of this "double or triple the risk" argument originated with the notorious homebirth opponent Dr. Amy a few years ago, where she compared MANA homebirth data against low-risk hospital birth statistics.  She over-focuses on neonatal death risks and steadfastly refuses to learn anything from her debate opponents, but she does make a good devil's advocate.

 

 

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post #13 of 394

Vaske, I object to this line of thinking "Many homebirth parents skip prenatal testing and ultrasounds (and selective terminations)". 

 

Although I understand that that is frequently the first question when  prenatal testing like a nuchal translucency is offered, it is not the sole reason for the testing.  II explain to parents that if their baby does have Down's, about 50 % of those babies also have a serious heart defect, and a smaller percentage have some form of TEF.  OOH birth is not safe in those circumstances. If parents want prenatal testing done it is to make sure their baby is normal and an OOH birth would be safe. In the case of Trisomies 13 and 18 some of those babies don't survive the pregnancy , and if they do, they are terminal, incurable and medically fragile for their short life.
 

The babies I have seen die at home birth have been due to the negligence of the midwife. These include breeches, preterm babies with cord accidents, post due babies with MAS, unrecognized chorioamnionitis, unrecognized and untreated placental abruption, GBS sepsis in the newborn, undiagnosed maternal diabetes, obstructed labor, and uterine rupture. Then there are the things that midwives do in the name of "helping the labor along" like giving cytotec or pitocin, in some cases without informing the laboring woman.  All of these were things the midwife thought she could handle at home rather than transferring the woman or her baby to the hospital. If you don't think these things happen, all you need to do is a google search and the women's stories will show up, a lot of them.

 

In other countries where midwives need a university level education at a federally approved midwifery program, and need a license to practice, these things happen rarely. If they do occur  they are signs of gross negligence and incompetent care. There is no excuse for any midwife to ever take that kind of risk with another woman's child, or the woman herself.

 

Don't blame Dr. Amy when the fault lies with an undereducated, unlicensed, unregulated midwife. And before you tell me that licensing does not make better midwives I would ask you to show me the evidence rather than repeat the platitude.

post #14 of 394

Actually in Europe as well as the UK most midwifery programs are direct entry and do not require a nursing degree. I do agree that there are some shady midwives practicing in the USA who may be uneducated or not practicing safely. However there are many who are educated and safe. I do agree that regulations should be put into place to ensure that a midwife is up to snuff so to speak.

post #15 of 394

Has the EU recently changed their guidelines for  midwifery education in Europe?

When I checked last week (documents fro  2011) almost every country required nursing as a prerequisite to entry into a university level midwifery program.
 

post #16 of 394

Not that I know of, the UK has had direct entry midwifery for a few decades and none of the other countries I have looked up required nursing... I haven't looked at them all though but for example the Netherlands is direct entry as is Denmark.

post #17 of 394

I am looking at EU reports from 2009 and for direct entry a 36 month program is required. If the applicant has a nursing degree (equivalent of RN here)  then they can do the 18 month program.

I will need to go recheck, but I believe at least one year of university classes is required as a prerequisite for the direct entry route.

 

"Direct entry" is used differently  in the EU than it is here. In the EU it only means that a nursing degree is not needed as a prerequisite for entry to a midwifery program. It would be similar to a Certfied Midwife (CM) here. A non-RN who completes the same university midwife education as a CNM and takes the same AMCB exam. In the US, "direct entry" usually means becoming a midwife through apprenticeship with no college classes required. It would be similar to the undereducated traditional birth attendants (TBAs) found in developing countries. For the most part, US direct entry midwives would not be able to meet the registry requirements in the UK or EU. As I am researching midwifery education standards worldwide, I'm pretty sure that most US direct entry midwives would not meet educational and registry requirements in most of the world, but they would as unlicensed TBAs.
 

post #18 of 394

My 2 cents is that if we accept the 3 times the death rate at face value we need to understand we are talking about 1 in 1000 vs. 3 in 1000. That is not the kind of stat that has me overly concerned.

 

However, as everyone here is pointing out, the midwife you choose can make all the difference. For that reason and others, when my midwife was no longer available I chose hospital birth with my last baby.

 

Also, reportings can be flawed. My understanding for my state was that until last year all deaths of babies whose parents had planned to give birth at home were reported with no differential between where birth actually took place and circumstances of death. Which means that reported homebirth deaths included a baby whose death I know for certain was not the result of a home birth plan. 

post #19 of 394
Quote:
Originally Posted by starrlamia View Post

Not that I know of, the UK has had direct entry midwifery for a few decades and none of the other countries I have looked up required nursing... I haven't looked at them all though but for example the Netherlands is direct entry as is Denmark.
I can say the same for Germany. There neither nursing nor midwifery is a university based degree/program. Both nurses and midwifes do a combined vocational college/apprentice type education, usually in hospitals to become either a nurse or a midwife. The duration of the program is typically 3 years. Nurses wanting to become midwifes may have an option for accelerated programs... But technically you do not even need the equivalent of a high school degree (abitur or 12 years of school) a "middle degree" (mittlere reife or 10 years of school) is sufficient to enter the midwifery program.

This website gives a good overview of the German midwifery education, but it is in German, so you may have to run it through a translator: http://www.ausbildung-hebamme.de/Ausbildung-Hebamme.html

The European education system (and the German in particular) can be very confusing if you are not familiar with it. A lot of credentials that you would consider university degrees in the US are not. As a matter of fact university degrees in nursing and related professions are only very recent developments there and the scope of practice of the profession is different as well.

Mothercat, I am not sure what your sources are, but fairly certain that you may want to recheck at least for some countries.
Also take into consideration that it is not as uniform as some sources may make you believe. A lot of information in EU documents are guidelines and suggestions rather than what is common practice in member states.

Good luck with your research!
post #20 of 394

:S sorry, the USA seems to be the only country who doesn't use direct entry in the same way as the rest of the world. I was using the term in the sense of not needing a nursing degree. But that doesn't change that most European countries do not require a nursing degree to become a midwife.

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