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Cornell Study - 4x higher rate of death at Homebirth - Page 2

post #21 of 61
Thing is, an emergency c/s doesn't seem all that "heroic" in terms of being extraordinary, complicated, or expensive. Shaving off 30 minutes of decision to incision time may very well mean the baby survives with very little, if any, damage. I think parents should at least be given the full information, that if placental abruption or uterine rupture or cord accident happens in the hospital, their baby will probably be born alive but possibly with brain damage, vs if it happens at home, the baby is more likely to die, either before birth or within a couple days.
post #22 of 61

Those who are interested in the risks of brain injury should take a look at this study: http://www.ajog.org/article/S0002-9378%2813%2901604-9/fulltext

 

The authors found that the risk of suffering hypoxic ischemic encephalopathy was 16.9 times more likely at a homebirth.  As far as I can tell, most of these babies survived with varying degrees of brain injury.

 

There's been a lot of data that's come out lately that shows us that there are some pretty substantial issues with the way home births are being done in the United States.  Organizations like MANA should be doing everything in their power to come up with appropriate procedures and guidelines to institutionalize best practices and figure out how to prevent bad outcomes, but it seems that they're content to pretend that the problem doesn't exist. 

post #23 of 61
My question would be where did it put women who planned on delivering I the hospital who didn't make it there? Because that is where I would put a large number of home birth fatalities.
post #24 of 61
Thread Starter 
Quote:
Originally Posted by isisandshiva View Post

My question would be where did it put women who planned on delivering I the hospital who didn't make it there? Because that is where I would put a large number of home birth fatalities.

 

It put them in the "home birth 'others'" category. That group had 18.2 baby deaths for every 10,000 births. They were not counted as part of the planned home birth/"home birth with midwives" category (which had 13.2 deaths per 10,000 births).

post #25 of 61
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post #26 of 61
Oops, nevermind.  Apparently I clicked on appalled's link instead.  I was confused there for a bit.
post #27 of 61
Quote:
Originally Posted by Katie8681 View Post

Thing is, an emergency c/s doesn't seem all that "heroic" in terms of being extraordinary, complicated, or expensive. Shaving off 30 minutes of decision to incision time may very well mean the baby survives with very little, if any, damage. I think parents should at least be given the full information, that if placental abruption or uterine rupture or cord accident happens in the hospital, their baby will probably be born alive but possibly with brain damage, vs if it happens at home, the baby is more likely to die, either before birth or within a couple days.

Katie, when I initially read your reply about the difference "30 minutes" makes, I thought you were making a comment that I always make related to the perceived "safety" of hospital birth.  In many community hospitals there is no surgical team, anesthesiologist and sometimes no obstetrician in the hospital on off hours; the general rule being the on-call staff must be within 30 minutes of arriving at the hospital.  To find out this information about the hospital in which you plan to have you baby is nearly impossible.  A very well-respected doctor that works at my local hospital responded, when asked if the hospital has the ability to do an "immediate" C-section, "We have 24-hour anesthesia coverage."  This didn't answer the question at all, because that means, the needed anesthesiologist might be sound asleep at home at 1 o'clock in the morning when you arrive at the hospital with a prolapsed cord, but s/he is indeed "on-call."  I worked at this hospital and know this is how it works.  Anesthesia is often not available even in the middle of the day because they're doing tonsillectomies and gallbladder removals.  In other words, Katie, you are right; 30 minutes makes a huge difference in those instances you list--but the 30 minutes might be the patient transporting from home to hospital or the hospital patient waiting for the surgical team to arrive 30 minutes later from home to hospital.  Which is safer?

post #28 of 61
Quote:
Originally Posted by joycnm View Post

In other words, Katie, you are right; 30 minutes makes a huge difference in those instances you list--but the 30 minutes might be the patient transporting from home to hospital or the hospital patient waiting for the surgical team to arrive 30 minutes later from home to hospital.  Which is safer?

You make the assumption that they are mutually exclusive when in fact, they are more likely to be additive. If your hospital takes 30 min from decision to incision, you can add on to that a 30 minute transport time from home to hospital. A midwife with the system access to coordinate an arrival straight into the OR with a surgeon and the rest of the crew ready to go is damn near unheard of in the US. Let's be real. Having to transport from home can only increase decision to incision time. And that is probably why the rate of term intrapartum IUFD is higher at home births. I used to want to attend home births, but I don't see how I can ethically do so, knowing the small but significant increased risk of perinatal mortality that it entails.
post #29 of 61
Quote:
Originally Posted by FisherFamily View Post

It makes me wonder about outcomes other than death. A baby who was the victim of a placental abruption may die at home, but the same baby in a hospital may live...and live forever.severely.brain damaged. Maybe saving a life with medical heroics is the right priority, but I'm not sure.

 

Uh.  Babies who experience hypoxic events during birth have a wide range of outcomes from no issues to mild developmental delays to severe issues to death.  A timely c-section saves a lot of kids a lot of suffering - meaning they come out very healthy.  Some may be disabled but still be able to enjoy their own lives.  If a baby is found to be so injured that s/he has no hope of healing or quality of life, parents can and do make decisions to discontinue interventions that don't support healing and allow that child a peaceful death.  But you can't know before you've begun to try whether that child has a hope or not.

post #30 of 61
Quote:
Originally Posted by cyclamen View Post
 

 

Uh.  Babies who experience hypoxic events during birth have a wide range of outcomes from no issues to mild developmental delays to severe issues to death.  A timely c-section saves a lot of kids a lot of suffering - meaning they come out very healthy.  Some may be disabled but still be able to enjoy their own lives.  If a baby is found to be so injured that s/he has no hope of healing or quality of life, parents can and do make decisions to discontinue interventions that don't support healing and allow that child a peaceful death.  But you can't know before you've begun to try whether that child has a hope or not.


Sure, and I would hope that my child (or any child) would have the best chance possible.  I'm just saying that death isn't the only standard to determine whether a hospital birth is better than a home birth.  I have read accounts of parents who have been devastated that the few minutes their child was alive was full of tubes and poking and etc trying to save them, when the parents would have rather held their baby peacefully.  I know it is very hard, because you can't know.  But, that is a reason why the mother of the child ought be allowed to chose where and how she wants to birth.  Yes, informed consent.  No to mandating.

post #31 of 61

Who want mandating?  I don't support mandating.  

 

As to the rest of it... wow.  It is so, so common to feel regret, if your child's life was cut short, that any moment of it was not peaceful.  It is sooo common.  It's common to wish that every moment had been peace.  I have wished the very same thing.  That is not the same thing as being in the midst of an emergency of unknown severity and outcome and saying, "Oh well, let's not bother, he probably would have been brain damaged anyway."  I think you will be very hard pressed to find anyone who thinks that.

post #32 of 61
Thread Starter 
Quote:
Originally Posted by FisherFamily View Post
 


I have read accounts of parents who have been devastated that the few minutes their child was alive was full of tubes and poking and etc trying to save them, when the parents would have rather held their baby peacefully.  I know it is very hard, because you can't know. 

 

And I have heard accounts of other parents who are glad that those first moments were full of tubes and poking because it didn't just mean the doctors were trying to save the baby, it meant the doctors did save the baby. It meant their baby lived and did not die peacefully in their arms. It is hard because yes, that's something that can only be seen in hindsight, once it's known whether the baby is going to make it.

 

I agree with you and cyclamen - no mandating. Women should not be forced to birth anywhere, and they should be have full information for their options.

post #33 of 61

If anyone has a problem with this specific study it is worth noting that multiple other studies have duplicated the same risk data (including MANA's own numbers released this year). Results that are repeated across multiple studies are the best indicator of sound science. This is at least the 3rd large study I have seen that said there was a 3-5x increase in perinatal mortality in low risk populations. 

 

These are just the facts that I have seen. I am not trying to judge anyones decision to birth out of hospital (I chose to, after all).

post #34 of 61
Quote:
Originally Posted by MidwifeErika View Post
 

It makes sense to me in that transports that are appropriate and timely probably resulted in wonderful outcomes and I would bet very, very, very few of those babies died. So, if the intended place of birth was home, the midwife transported appropriately for, say, thick meconium, baby was born healthy in the hospital, that outcome would be recorded as a hospital birth. If midwives are transporting 10-15% of the time and those outcomes are great, it reduces the total number of homebirths to divide in the intrapartum death rate. In an ideal transport situation, those calls are made at the first sign of issues and then the woman and her baby get excellent care in the hospital setting and they should have a wonderful and healthy outcome. Am I making sense or do I need another cup of coffee this morning?

 

Regarding the bold, it does make sense that appropriately timed transports would have good outcomes.  But.... would we really expect them to have better outcomes than women who remain home?  A lot of transports are for pain relief rather than an emergency or dangerous situation, though there are of course those who are transported due to warning signs or outright emergency.  Still though, it is generally not the mother who are handling the pain okay an having quick to normal length labors with no troubling signs who transfer.  

 

If the group of exhausted + in too much pain + some warning signs + the rare super-bad emergency resulting in transfer actually has a much better outcome rate than the mothers who are fine to stay home, then that right there is a pretty big problem that needs looking into.  

 

Lets say that they do have a low NMR that including them would lower the overall NMR for planned homebirth.  Just how much could they bring it down?

 

There were 48,202 homebirths attended by midwife in the study.  At a NMR of 13.2 per 10,000, that represents about 64 deaths. 

 

If there were a 15% transfer rate, then 48,202 represents 85% of the total number births which would be about 56,708, and there would have been 8506 transfers. 

 

Let's say that every one of those transfers survived and the only deaths in the planned homebirth group, so still 64.

 

64/56708*10000= 11.3 

 

So all those living transfers do bring the overall rate down a bit since 11.3 is less than 13.2.  But... still doesn't come close to 6.3 for a freestanding birth midwife, 5.4 for hospital MD, or 3.1 for hospital midwife. 

 

Conclusion: unless the actual transfer rate is much higher than the 15% we keep hearing, the inclusion of homebirth transfers in hospital births rather than as planned homebirths can not significantly raise the homebirth NMR and thus can not be the cause of the high rate. 

 

The thing is though, that while this can tell us something about the average state of homebirth is in the US right now, it does not actually tell us that much about what the risk for particular low risk woman might be.  It does not tell us how good homebirth could be in an ideally set up system. It's my impression that hospital based midwives are on average much quicker to risk out women to OB care than many homebirth midwives.  Breech, in particular, will mostly be a c-section in a hospital and even if done vaginally is unlikely to be delivered by a CNM.  On the other hand, we know from the MANA study that there are breeches being delivered by midwives at home an they have a very high NMR.  While there are some risk factors you can eliminate on the CDC database (such as twins), it does not have any information about breech/vertex, so how many of those 64 homebirth deaths were breech?  

 

I am upset by all the attempts to explain away the higher mortality rate as not real or not worth caring about or brushing it under the rug instead of looking into it and trying to find out why it is that way and what can be done to lower it or at least inform women of how much risk each factor such as breech and VBAC is.  If a women assesses the risk and decides it is one she is willing to take that is one thing, but how can she make an informed decision when she's being told over and over that a breech birth or triplets or whatever is just a variation of normal and just as safe or safer to do at home than in the hospital?

 

I absolutely support the decision of a low risk woman to have a homebirth with a good midwife and a plan set up for smooth and quick transfer if needed.  There are other births where I may think the mother is making a foolish or dangerous choice, but it is her body and her life and her baby, not mine, so I still absolutely support her right to make that choice  even if I don't agree with the one she makes.  What I do not support is sweeping the risks under the rug instead of dealing with them honestly.  

post #35 of 61
Quote:
Originally Posted by pers View Post
 

  While there are some risk factors you can eliminate on the CDC database (such as twins), it does not have any information about breech/vertex, so how many of those 64 homebirth deaths were breech?  

 

I am upset by all the attempts to explain away the higher mortality rate as not real or not worth caring about or brushing it under the rug instead of looking into it and trying to find out why it is that way and what can be done to lower it or at least inform women of how much risk each factor such as breech and VBAC is.  

You bring up a very interesting point re:breech as it may play into those numbers.

 

I hope you do not feel like i am trying to explain it away. I am not. Really. 

post #36 of 61

Oh no, sorry, I sort of switched streams at the end there from talking to you to talking about others who are saying it at a much more formal level. 

 

I took the way you said it as speculating/brainstorming and asking questions, which is all good.  But it's just the start of the process.  And here on a message board in a quick post, it's okay to throw maybes and possibilities out there.  But I've heard the same thing from Big Names speaking to large audiences from positions of authority and presenting themselves as experts on national birth statistics, and as such they have a much higher level of responsibility to follow it through into at least actually looking into it and whether it could make a substantive impact on the numbers.  I don't see any evidence that they have done that.  And they are not just throwing it out there as a possible explanation to consider but actually saying that the numbers can't be compared. 

post #37 of 61
Thread Starter 

I think the breech numbers are very interesting (and tragic) as well. In the MANA data that just came out, they reported:

 

Quote:
 Of 222 babies presenting in breech position, 5 died either during labor or the neonatal period.

 

That's a huge number! That's a rate of almost 22.5 deaths per 1000 babies born. Breech babies born in the hospital have a rate of 0.8/1000. So breech babies born at home died at a rate 28 times higher than those born in the hospital. That's HUGE. That's beyond huge. How can any midwife accept known breech clients knowing that information? How can anyone encourage a breech home birth with that knowledge?

post #38 of 61
I have to back Pillowy here. One of the arguments I seem to here a lot is that the risk of homebirth may be *higher* then the risk of hospital birth, in absolute terms, it's still low risk. The breech numbers, however, are appalling. More then 2% of breech babies delivered by homebirth midwives in this dataset died. That is just not low risk.
post #39 of 61
Quote:
Originally Posted by Pillowy View Post
 

I think the breech numbers are very interesting (and tragic) as well. In the MANA data that just came out, they reported:

 

 

That's a huge number! That's a rate of almost 22.5 deaths per 1000 babies born. Breech babies born in the hospital have a rate of 0.8/1000.

What disturbs me as a home birth CNM is that almost all studies determining the safety of home birth ignore the one factor that makes the birth safer and that factor is the education, training and experience of the birth attendant.  One study promoted by ACOG included accidental births without ANY provider present--of course that would show home birth to be unsafe!   They can accurately say, "Home birth 3 times risk of newborn death!" because if you have a premature baby at home by accident, it has a 3 x (probably more) risk of dying.  But that's not what the uninformed general public reads in the headline, right? It is only my supposition that with the MANA study and the Cornell study, they do not delineate the difference between the competency of the "midwife" attending the births.  I wouldn't be surprised if some of the MANA births included the horrible outcomes made public from the Oregon statistics that included "midwives' with very little training and almost no education or experience.  We must compare apples to apples.

post #40 of 61
Thread Starter 

Yes, I agree that the education, training, and experience of the birth attendant are extremely important. These numbers that were talking about in this thread - the 4x higher rate of death - include only births attended by midwives, not accidental home births. 

 

So you would you like to see a study that broke down which births were attended by CNMs, CPMs, DEMs, LMs, and so on? What would you do with that information? If it was shown that those with more education and training - CNMs - had much lower death rates than the other midwives, would you want there to be regulations that everyone must meet that minimum standard before selling their services as a midwife?

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