Thoughts on "planned home births are associated with double to triple the risk of infant death... - Page 2

[krst234]

"Direct Entry Midwife" in the US can mean a person who calls herself a midwife who has had no formal training or education at all. It may also mean a CPM. Or a CM. I've even heard graduate midwifery schools call their programs call their BSN-MSN/CNM programs "direct-entry" programs as well. This makes it exceptionally confusing.

European countries have "direct entry" midwifery programs. There really is no equivalent in the US. The key distinction between European "direct-entry" programs and DEMs in the US is the European midwifery programs require formal education. Being a "DEM" in the US requires no training, no education, no certification exam. Most midwives who refer to themselves as DEMs in the US are of this variety.

All other US "direct-entry" midwives would refer to themselves by their professional credential. (CPM, CM)

I doubt there is a European midwifery program equivalent to American DEM training or even the CPM training process. And I think the point mothercat is trying to make is that American midwives often use studies from Europe to support OOH practices in the US - when, in fact, there really are considerable differences in terms of training and formal education of midwives.

Which gets back to the original question - are there increased risks in OOH birth? And can we expect the same outcomes from midwives who were trained differently? Do CPMs have equivalent outcomes as CNMs? Do DEMs or lay midwives have equivalent outcomes as CPMs or CNMs? Does licensing of midwives improve safety and outcomes? Does training and integration into the health care system make a difference in outcomes?

I would venture to say yes. That the training and skill and legality of the midwife matters in providing safe care and assuring the best outcomes for mothers and babies.

[mwherbs]

The CDC wonder pages say that the numbers are too small to get accurate stats. If it were clearly 2-3 times the death rate they wouldnt be papers published like the Pang study- which included all births outside the hospital- not the stats the the health department kept on midwife attended births- and that poorly done old study keeps getting rolled into any other new study. If you look at the BC Canada study- and i know that they did not switch over to a new requirement and change from cpm home only to home and hospital intergration- the first class graduating from that school wasnt done till after the study was completed...
In Az they just rifeled thru all the available records and included all reported losses- and i say losses because miscarriages were included in the raw numbers and the infant morality with those included was still lower than hospital mortaliy... The johnson and davis study showed - An number closer to parity with reported Hospital infant mortality- and they called midwife attended births low risk, and that is a very tricky term, and is nver well defined, and midwives and doctors do not agree on the definition of low risk- an example would be that physicians consider larger babies to be high risk, yet midwives catch babies that on average are larger than hospital counterparts, so are these high risk births or not or something else that the CDC found that home birth moms tend to be well educated OLDER moms , OLDER moms according to other medical studies are high risk with greater chance of stillbirth and other complications...
When i spent some time using the CDC wonder pages- and by the way the stuff that gets sent into them in inaccurate in atleast 2 states I know of and it may be all the states, because there data is blinded data- and there is no checks and balance to be sure that the birhs/deaths are not being double reported once by the hospital and once by the midwife---in my state there is a Rule that says if the placenta is delivered at homethen the midwife files the birth certificate, and i know midwives file those birth certificates, then what I have seen is that hospital staff fills out a birth certificate as well now the baby usually only gets one birth certificate but all the stastical data that is reported is on the forms is double reported or slightly different ye double reported--- usually the hospitals will say that women who have midwifery care actually get no prenatal care... And stuff like that. I found on the wonderpages that there are Doctors of osteopathy who attend births in the hospital and that their percent of births is similar to midwife attended homebirths and their infant mortality rates are similar.

[phathui5]

Originally Posted by starrlamia 

: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.

It's a shame that the US doesn't have the midwifery education programs available that women in the UK are able to take. 

[Escaping]

I find these kinds of statistics and comparisons irrelevant. Childbirth is not roulette. Healthy women with healthy pregnancies and "normal" babies are able to deliver at home safely, that's been established throughout history. Properly vetting women and assessing situations and health conditions is what ensures a safe home birth. It isn't just the understanding that 3 out of 1,000 babies born at home are stillborn and you just try not to be one of them. The problem is some agendas are out to convince people that all doctors are evil, all women can go overdue as long as they want, all women can stay in labor for days and all women can have a safe home birth. That's just not true. 

[eabbmom]

Childbirth is roulette. You can be informed and make good decisions, be healthy and willing to change course if needed and still get the short end of the birth stick. I believe in homebirth and hospital birth. Walking into the hospital is roulette. Your nurse on staff, charting, overseeing dictor, midwife on call can all play into intervention happening and falling into the cascade. One docs failure to progress can be another docs variationof normal. The same statistics that say homebirth is more dangerous for bub also find hospital birth is more dangerous to mum. Homebirth can also be roulette. Midwives have insanely different standards and training. Going on recommendations of others can also be problematic when finding a midwife bc women who have poor outcomes often feel they can't speak out in the ncb community. Propaganda is everywhere. Doctors play the dead baby card too often, push for tests that do not change outcome, rush birth. MWs can avoid transfer when necessary, not refer out high risk patients or make poor calls. Childbirth, like all things involving human judgement, is roulette. 3 out of 1000 is an extremely meaningful stat if you are one of the three.

[starrlamia]

great post eabbmom!

[mwherbs]

Yes and hospital death rates 5-6/1000, Or higher depending on region and race. Hospital roulette indeed 1/3 and in some places like Flordia 40% c section rate... Maternal death rates are higher, sick and very sick infants higher in hospitals -- in the CPM study one of the deaths occured after transfer to the hospital and they did routine rupture of membranes and the baby's cord prolapsed- so that was atributed to home birth death even though mom was approprately transfered to the hospital and was brought on by routine hospital intervention...

[krst234]

Properly vetting women and assessing situations and health conditions is what ensures a safe home birth.

eabbmom)

Midwives have insanely different standards and training.

I concur.

These are important points that should not get lost in the discussion around home birth. Too often, they do.

[mothercat]

Originally Posted by mwherbs 

Yes and hospital death rates 5-6/1000, Or higher depending on region and race. Hospital roulette indeed 1/3 and in some places like Flordia 40% c section rate... Maternal death rates are higher, sick and very sick infants higher in hospitals -- in the CPM study one of the deaths occured after transfer to the hospital and they did routine rupture of membranes and the baby's cord prolapsed- so that was atributed to home birth death even though mom was approprately transfered to the hospital and was brought on by routine hospital intervention...

One out of how many births in the CPM study? I'm assuming you are talking about Ken and Betty Ann's study. Whether that was statistically significant would have to do with how many women were in the study.   Wasn't it more than 10,000? And it is a red herring to say that the same thing happens in hospitals, meaning we sort of expect that a baby's death may also happen at home.  I don't think that is much comfort to the family it happens to.

The standard is that only women with no identifiable risk factors before or during pregnancy, or during  or after labor, should be birthing OOH. Those are the women having normal pregnancies and births, and that is who midwives  who do out of hospital births say they take care of. To include women who have some complications is changing the ground rules and the "home birth is safe" studies no longer apply. It is disingenuous to say that home birth is safe without also mentioning the training of the midwives in the countries where those studies were done.  Even with the CPM study, not all CPMs and certainly not all LMs, DEMs, community midwives, etc participated. Yet, all those groups of midwives are more than happy to promote the studies showing that the place is safe, but they don't explain the part that the midwife's education , or the larger health system, played in making that place safe.

I think that should be labeled as a bait and switch.

[A2JC4life]

Studies in the UK showed that out of hospital births had better outcomes at every risk level.

[Buzzbuzz]

What are you talking about!??!!  What you describe is simply not the result of the UK's Birthplace Study.

[Buzzbuzz]

"The standard is that only women with no identifiable risk factors before or during pregnancy, or during or after labor, should be birthing OOH."

I believe the Birthplace Study in the UK also found elevated risk for primiparas.  Out of curiosity, in your analysis are you including them as homebirth eligible or do you consider an untried pelvis as an "indentifiable risk factor" that should cause a woman to be ruled out of homebirth?

[rachelsmama]

Stats can only take you so far, you really need to look at your available options too.  If your only available hospitals are large, chaotic with a high infection rate and a high intervention rate, but there are highly skilled midwives available, then the situation is much different than if the only available midwives have questionable training and skills, and there's a nearby hospital with a suitable level of skill and respect for the birthing mother and the birthing process.

[phathui5]

Here are findings from the birthplace study:

https://www.npeu.ox.ac.uk/files/downloads/birthplace/Birthplace-key-findings.pdf

https://www.npeu.ox.ac.uk/files/downloads/birthplace/Birthplace-Q-A.pdf

[Escaping]

Originally Posted by A2JC4life 

Studies in the UK showed that out of hospital births had better outcomes at every risk level.

Originally Posted by Buzzbuzz 

What are you talking about!??!!  What you describe is simply not the result of the UK's Birthplace Study.

If it's true, I can see the stat making sense... in the UK if there are complications, you're transferred to a hospital. In addition to just labor complications, hospitals also have to deal with birth defects, traumas, drug addicts, etc.

[Buzzbuzz]

I would be intrigued to learn how the UK is managing, for example, pre-eclampsia or placenta previa at a home birth just as well as in the hospital.  Otherwise, every risk level is NOT having the same outcomes.

[mothercat]

Originally Posted by Buzzbuzz 

"The standard is that only women with no identifiable risk factors before or during pregnancy, or during or after labor, should be birthing OOH."

I believe the Birthplace Study in the UK also found elevated risk for primiparas.  Out of curiosity, in your analysis are you including them as homebirth eligible or do you consider an untried pelvis as an "indentifiable risk factor" that should cause a woman to be ruled out of homebirth?

No, an untried pelvis is not an identifiable risk factor.  Although from stats tracked by AABC, they indicate that about 40% of primips will transfer to hospital from birth center care, but that doesn't mean it was a problem with the pelvis. Most of those are prolonged labor or a request for pain medication.

Edited by mothercat - 3/8/13 at 7:42pm

[Escaping]

Originally Posted by Buzzbuzz 

I would be intrigued to learn how the UK is managing, for example, pre-eclampsia or placenta previa at a home birth just as well as in the hospital.  Otherwise, every risk level is NOT having the same outcomes.

They don't, at the first sign of complications they're transferred to the hospital. That's why their home birth stats are so good.

It's kind of like my mom's logic: she always gets the new car which require zero maintenance, then when they get older she gives them to my dad and she gets another new one. When my dad drives them, they all start to require repairs and maintenance... she insists because it's the way she drives the cars that her cars have never required new batteries, tires, etc. but as soon as he starts driving them, "all sorts of things start to go" lol

[mwherbs]

Except that what all do they consider " risk factors" they do midwife managed breeches and consider that normal...

[mwherbs]

Here is a Cdc paper on the demographics of homebirth families-    http://www.cdc.gov/nchs/data/databriefs/db84.pdf

And here is a report on infant mortality and causes
http://www.cdc.gov/nchs/data/nvsr/nvsr61/nvsr61_08.pdf
  

And i would have to say that mothercat, has some good points there are all sorts of chancers out there, drugs for induction increase the risks to dangerous levels for baby and mom , i have heard of this being done by doctors , CNMs and midwives and is in no way low risk in or out of hospitals or birth centers.
And there have been some heart Breaking losses reported on home births, i know in reading over some of the stories things may have turned out differently, in others i have read where mom was seen and tested/screened and then went home i am not sure that anything could have been done to change the outcome in that pregnancy. It does not hurt to review such cases to help learn from other's losses or mistakes.