Identity, as far as I can tell, this number is artificially lower than it should be, because the "home birth, midwife" only includes the births that actually have the midwife as the attendant of record. This also would perhaps hide home births with a midwife due to states where home birth midwifery is illegal, so the birth is recorded as an unassisted birth. Those numbers are probably worse and they are not included in the "10-18x higher" risk.
Any emergency transfer should go into the "hospital, MD" column. Further, I believe that any birth that happens with paramedics in the field, or possibly even any birth where baby is out but placenta is delivered at the hospital would go into "hospital, MD." At some point, it sort of becomes a question of how confident we are in the skills of the home birth midwifery community to correctly identify fetal distress and transfer appropriately. If we are going to say that the 10x higher risk is the worst case scenario, where there are no babies in the hospital numbers who should have been in the home numbers, that would only make sense if no home birth midwife was able to correctly identify fetal distress and transfer. I mean, to get to an Apgar of 0 at 5 minutes, you're talking about serious and prolonged fetal compromise, not a brief cord compression in late 2nd stage. If we say that the midwives who did not transfer appropriately or who had a serious, s*** hits the fan scenario with no real time to respond or get to higher levels of care were in the minority, how many people should have been in the home birth group who weren't? Were there 5 times as many midwives who transferred as who didn't? All I need is 20 babies in the entire US in the entirety of the period of time covered in this study miscategorized and we're looking at a 13x higher relative risk home, midwife vs hospital, MD and a 23x higher relative risk home, midwife vs hospital, midwife.
The one real weakness that I can see is that it is unclear to me that we are talking about vertex presentation. These are singleton, full term, not low birth weight, but we don't know if these kids are vertex or breech as far as I can tell. If that point could be clarified by the authors, it would be awesome. I want to know how many of these cases are breech head entrapments. But even if we make fully half of the extremely low Apgars due to breech, is a 5x-9x higher risk of profound fetal compromise low enough that it shouldn't be disclosed to women interested in home birth?
I would really love for Science and Sensibility or some of the other birth advocacy and education groups to look at this study and give their perspective. All I'm hearing is silence, and the silence is damning.