Cornell Study - 4x higher rate of death at Homebirth - Mothering Forums
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#1 of 61 Old 02-04-2014, 05:25 PM - Thread Starter
 
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I was looking to see if this has been posted yet, but I don't think it has. Has anyone seen this yet - "Home Births Tied to Higher Infant Death Rates"? It's a new study done by Cornell University.

 

They used the CDC data on almost 14 million births and deaths, and compared the numbers for babies delivered by midwives in a hospital and babies delivered by midwives at home. They found a 4x higher rate of death for babies delivered at home.

 

Several quotes from this article concern me:

 

"The researchers found that the absolute risk of a baby dying at birth or in the 28 days following delivery was 3.2 per 10,000 births when a midwife delivered the baby in a hospital, compared with 12.6 per 10,000 births when a midwife delivered the baby at home."

 

and

 

"Stillbirth is one of the most common complications, he said. Stillborn babies are not breathing at birth, but with immediate care many of them could be saved. 'Women who are thinking about having home birth should know that if they deliver in the hospital with a midwife, it reduces infant death by 75 percent -- and by 85 percent if the woman is having her first baby,' Grunebaum said. 'These are babies who could be saved if they were delivered in a hospital.'"

 

Melissa Cheyney criticized the study, saying "U.S. birth certificates do not reliably track intended place of birth. This means that between 10 percent and 25 percent of women who intended to deliver at home, but who transferred to the hospital during labor, have their outcomes erroneously recorded as hospital deliveries." But hospitals still had better results, even with the higher risk homebirths being transferred in. So I can't see how this criticism would mean that homebirth is any safer than these numbers show.

 

What is everyone's thoughts on this?

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#2 of 61 Old 02-04-2014, 05:29 PM
 
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Melissa Cheyney criticized the study, saying "U.S. birth certificates do not reliably track intended place of birth. This means that between 10 percent and 25 percent of women who intended to deliver at home, but who transferred to the hospital during labor, have their outcomes erroneously recorded as hospital deliveries."

If I'm reading this right, that seems like a really bizarre critique.  It seems logical to assume that outcomes where a mother had to transfer to a hospital in the middle of a home birth would tend to be worse than with births that were completed at home.  I would think that the numbers would be worse for home birth and better for hospital birth if the authors had included these cases in the home birth group.

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#3 of 61 Old 02-04-2014, 05:33 PM - Thread Starter
 
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If I'm reading this right, that seems like a really bizarre critique.  It seems logical to assume that outcomes where a mother had to transfer to a hospital in the middle of a home birth would tend to be worse than with births that were completed at home.  I would think that the numbers would be worse for home birth and better for hospital birth if the authors had included these cases in the home birth group.

 

Yeah, that's what I thought too...

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#4 of 61 Old 02-07-2014, 06:04 AM
 
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If I'm reading this right, that seems like a really bizarre critique.  It seems logical to assume that outcomes where a mother had to transfer to a hospital in the middle of a home birth would tend to be worse than with births that were completed at home.  I would think that the numbers would be worse for home birth and better for hospital birth if the authors had included these cases in the home birth group.

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?

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#5 of 61 Old 02-07-2014, 08:07 AM
 
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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?

Makes perfect sense to me!


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#6 of 61 Old 02-07-2014, 02:28 PM
 
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It doesn't make sense to me.  If you look at the tragic and rare stories where a baby dies following a planned homebirth, you'll see that in many (most? the vast majority?) of cases, there is a transfer to the hospital at some point before the baby is declared dead.  Those cases all end up being registered in the hospital column.

 

As a group, transfers are going to be more likely to be associated with complicated labors.  Complicated labors are going to be associated with higher rates of mortality and morbidity.  Most of the time, of course, the baby will be just fine after transferring.  And most of the time the baby will be just fine no matter where it is born.  But I still think that Cheyney is way off: I'm virtually certain that the stats would have been worse for homebirth and better for the hospital group if transfers were registered as homebirths. 

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#7 of 61 Old 02-07-2014, 04:26 PM
 
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It doesn't make sense to me.  If you look at the tragic and rare stories where a baby dies following a planned homebirth, you'll see that in many (most? the vast majority?) of cases, there is a transfer to the hospital at some point before the baby is declared dead.  Those cases all end up being registered in the hospital column.

 

As a group, transfers are going to be more likely to be associated with complicated labors.  Complicated labors are going to be associated with higher rates of mortality and morbidity.  Most of the time, of course, the baby will be just fine after transferring.  And most of the time the baby will be just fine no matter where it is born.  But I still think that Cheyney is way off: I'm virtually certain that the stats would have been worse for homebirth and better for the hospital group if transfers were registered as homebirths. 

 

But worse outcomes than when there is a complication and care is transported would be when there is a complication and care is NOT transported.

 

Most of the stories I have read have been the exact opposite of what you describe. Especially the stories that have made national news. 


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#8 of 61 Old 02-07-2014, 09:05 PM - Thread Starter
 
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But worse outcomes than when there is a complication and care is transported would be when there is a complication and care is NOT transported.

 

I'm not sure I understand what you're saying here. Do you mean, the homebirth statistics would be worse is there were complications and care iss not transported? Because yes, that is what apalled20 is saying too. The numbers would be worse if the care was not transported to the hospital.

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So the person who criticized the study said that since birth certificates don't record intended place of birth, we don't really know how the majority of the birthing time was spent.  I'm not sure if intended place of birth is important in evaluating the study, but if it is, then it's a valid criticism.  Now if you are saying she is in favor of home birth and is trying to discredit it and failing, then that is a different situation.

 

However, it's possible that what she is saying that since home births where transfers are needed and happen in a timely manner are all part of the home birthing experience, the transfers, many of which likely have good outcomes, aren't counted as home births, which they should be.  But if a transfer is needed and isn't done, and a baby dies, that gets counted as a home birth.  So that might be what she is thinking.

But then, If the intended place of birth is the hospital, and a mother doesn't make it there, for whatever reason, and then has a bad outcome somewhere else, is that recorded as a hospital birth?  Since many women do experience at least the first part of labor at home, if something happens before they get to the hospital, like a prolapsed cord or placental abruption or whatever, I would assume they would still be considered hospital births if the baby was born at the hospital, or even if the baby was born on the street or in a car or what have you. 

I'm wondering how important intended place of birth really is, and how it all plays out. 

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#10 of 61 Old 02-07-2014, 10:26 PM
 
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OK, I read the article and found this quote: "'It is unreliable and potentially misleading to compare groups when such a high percentage of your sample cannot accurately be assigned to one group or another,' Cheyney said."

So to me that sounds like she's just questioning the general accuracy of the study.

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I'm not sure I understand what you're saying here. Do you mean, the homebirth statistics would be worse is there were complications and care iss not transported? Because yes, that is what apalled20 is saying too. The numbers would be worse if the care was not transported to the hospital.


No, that's not exactly what I'm saying.  What I'm saying is that, as a group, mothers who plan a homebirth and end up transferring to the hospital are going to have a disproportionately high rate of bad outcomes.  The mere fact that they've transferred means that there is some sort of complication.  We know for a fact that most of them will go on to give birth to healthy babies and it may be the case that these complications have no bearing on the outcome for a large percentage of these mothers.  However, I don't think anyone can seriously claim that the outcomes for the group as a whole are going to be as positive as either: 1) low-risk mothers who chose to give birth in the hospital or 2) mothers who intended to give birth at home and did.  Enough of the complications are going to be of a serious enough nature as to be associated with a degree of risk that far exceeds that of an uncomplicated labor. 

 

Essentially, whoever gets this group is going to have their stats suffer as a result.  The study kicked these cases into the hospital column.  Had they been kept in the homebirth column, then the difference in safety would have been magnified further.  That's why it makes no sense for Cheyney to criticize the study on this grounds.  They actually did her a favor by counting these as hospital births.

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#12 of 61 Old 02-08-2014, 03:15 AM
 
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OK, I read the article and found this quote: "'It is unreliable and potentially misleading to compare groups when such a high percentage of your sample cannot accurately be assigned to one group or another,' Cheyney said."

So to me that sounds like she's just questioning the general accuracy of the study.

 

 

Here is the full quote:

 

"Cheyney, however, said there are significant problems with using this data to study outcomes by place of birth.

'For example, U.S. birth certificates do not reliably track intended place of birth,' she said. 'This means that between 10 percent and 25 percent of women who intended to deliver at home, but who transferred to the hospital during labor, have their outcomes erroneously recorded as hospital deliveries.'

'It is unreliable and potentially misleading to compare groups when such a high percentage of your sample cannot accurately be assigned to one group or another,' Cheyney said.

 

This criticism is incredibly disingenuous and hypocritical since MANA, the organization that Cheyney represents, quotes this data all the time when they think it helps them.  Her criticism has nothing to do with any actual methodological flaws.  She simply doesn't like the results. 

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#13 of 61 Old 02-08-2014, 07:23 AM
 
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Cheney is also making a mistake, because this study did not use birth certificate data, it used CDC data, which is very comprehensive and reliable.

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#14 of 61 Old 02-08-2014, 07:43 AM
 
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So there is some problem using birth certificates in determining intended place of birth at onset of labor.

 

According to information presented by the Institute of Medicine in March of 2013, only 31 states tracked intended place of birth in their vital statistics.

http://iom.edu/~/media/Files/Activity%20Files/Women/BirthSettings/6-MAR-2013/Paneth%20PDF.pdf

 

http://www.iom.edu/Reports/2013/An-Update-on-Research-Issues-in-the-Assessment-of-Birth-Settings.aspx <---link to the IOM webpage regarding birth settings workshop.

 

Babies can die days or weeks after an injury that occurred during birth. Yes, transfers from OOH can result in healthy outcomes, but transfers may not result in healthy outcomes, too.

If a baby dies from a birth injury 4 weeks after birth, did the intended place of birth influence the outcome? Sometimes, yes (hypoxia during labor OOH and a long transfer time). Sometimes no, (intended OOH birth transferred due to preterm labor at 30 weeks). What about appropriate transfer at onset of labor? Say a woman goes into labor at 40 weeks, but at onset of labor, the baby is discovered to be breech. The midwife appropriately risks the patient to hospital care. Regardless of the outcome, should this birth be counted in the 'intended home birth' column, or 'intended hospital birth' column?

 

It does get a little murky.

 

I do see the point that data collected one way (using vital statistics) may be an imperfect comparison to data collected in different manner (voluntary collection through MANA stats).

 

Perhaps a solution is to only use data from the 31 states that currently track intended place of birth.

If the Cornell study only examined data from the 31 states that track intended location of birth, would the results be different?

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So there is some problem using birth certificates in determining intended place of birth at onset of labor.

 

The study did not use birth certificates. It used the CDC linked infant birth/death data, which is very reliable. And it covers all 50 states.

 

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Originally Posted by Viola View Post
 

So the person who criticized the study said that since birth certificates don't record intended place of birth, we don't really know how the majority of the birthing time was spent.  I'm not sure if intended place of birth is important in evaluating the study, but if it is, then it's a valid criticism.  Now if you are saying she is in favor of home birth and is trying to discredit it and failing, then that is a different situation.

 

However, it's possible that what she is saying that since home births where transfers are needed and happen in a timely manner are all part of the home birthing experience, the transfers, many of which likely have good outcomes, aren't counted as home births, which they should be.  But if a transfer is needed and isn't done, and a baby dies, that gets counted as a home birth.  So that might be what she is thinking.

But then, If the intended place of birth is the hospital, and a mother doesn't make it there, for whatever reason, and then has a bad outcome somewhere else, is that recorded as a hospital birth?  Since many women do experience at least the first part of labor at home, if something happens before they get to the hospital, like a prolapsed cord or placental abruption or whatever, I would assume they would still be considered hospital births if the baby was born at the hospital, or even if the baby was born on the street or in a car or what have you. 

I'm wondering how important intended place of birth really is, and how it all plays out. 

 

The study looks at babies born by hospital midwives, hospital mds, freestanding birth center midwives, home birth midwives, and home birth "others." 

 

The CDC linked birth/data records where the baby was born and who delivered it. So, if someone meant to go to the hospital but accidentally delivered the baby at home (or if someone did a UB), that would be recorded as home birth "others." If a woman delivered at home with a midwife, that would be counted as a "home birth midwife" birth. If a woman meant to deliver at home but was transferred to the hospital because of complications, that would be counted as a hospital birth (probably hospital md).

 

With that in mind, the study found that (NNM = neonatal mortality rate, death from birth to 28 days old): "NNM for those delivered at home by others and by midwives, and those delivered in a freestanding birthing center was significantly higher than those delivered by midwives in the hospital: hospital midwives: 3.1/10,000 (RR:1); home others: 18.2/10,000 (RR: 5.87; 95%CI: 4.21-8.19), home midwives: 13.2/10,000; (RR: 4.32 95%CI: 3.29-5.68), freestanding birthing center: 6.3/10,000;(RR: 2.03; 95%CI: 1.28-3.24)."

 

This means that for every ten thousand babies delivered by hospital midwives, 3.1 died. For every ten thousand babies delivered by birth center midwives, 6.3 died. And for every 10,000 babies delivered by home birth midwives, 13.2 died.

 

Intended place of birth is important only so far as to know that only those planning to have home births with midwives and who were able to accomplish that were counted in that group. Those who were intending to have hospital births and had accidental home births were not counted in the home birth midwives group. And the hospital midwives and mds, which had both intended hospital births and home birth transfers, had a much lower rate of neonatal death than the home birth midwives.

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#16 of 61 Old 02-08-2014, 09:56 AM - Thread Starter
 
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Here's the actual study, since a lot of people will want to look at that: Term neonatal deaths resulting from home bIrths: an increasing trend

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 The study did not use birth certificates. It used the CDC linked infant birth/death data,

 

And the CDC collects infant birth/death data from where?

 

According to the CDC, this data is collected from birth certificates. Do you know of some other method used to document and record infant births?

 

http://www.cdc.gov/nchs/births.htm

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And the CDC collects infant birth/death data from where?

 

According to the CDC, this data is collected from birth certificates. Do you know of some other method used to document and record infant births?

 

http://www.cdc.gov/nchs/births.htm

 

Okay, and so what is the problem with the CDC data including birth certificates? Cheyney's criticism was that birth certificates do not track intended place of birth. But they do track actual place of birth, and whether it was with a midwife or with "others." And we can look at those numbers and see that babies born at home with a midwife have 4x the chance of dying than babies born in the hospital with a midwife.

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#19 of 61 Old 02-08-2014, 03:09 PM
 
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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.
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Vital statistics are recorded in a variety of ways. Birth certificates are one subset of the full vital statistics that are recorded at a birth, and the CDC data comes from that. I'm not sure how midwives record the data, but hospitals have an extensive data set they must complete at every birth. Part of that is recorded in the birth certificates that are sent to the state. The full data set is sent to the CDC. A lot of studies are based on CDC data, and it is generally considered a valid source.

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#21 of 61 Old 02-08-2014, 06:53 PM
 
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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.
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#22 of 61 Old 02-08-2014, 08:47 PM
 
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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. 

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#23 of 61 Old 02-08-2014, 09:23 PM
 
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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.
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#24 of 61 Old 02-08-2014, 09:42 PM - Thread Starter
 
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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).

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#26 of 61 Old 02-08-2014, 11:15 PM
 
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Oops, nevermind.  Apparently I clicked on appalled's link instead.  I was confused there for a bit.
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#27 of 61 Old 02-09-2014, 07:57 AM
 
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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?

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#28 of 61 Old 02-09-2014, 08:36 AM
 
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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.
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#29 of 61 Old 02-09-2014, 06:06 PM
 
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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.

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#30 of 61 Old 02-09-2014, 06:34 PM
 
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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.

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