Monday, July 16, 2012

Saraswathi Vedam's deeply disingenuous annotated guide to the homebirth literature



I never cease to be amazed at the pervasive contempt in which professional homebirth advocates hold their own followers.

  • Contempt for the intelligence of their followers: they are confident that followers can be easily tricked with long lists of citations;
  • Contempt for their unfamiliarity with forms of scientific literature: they are confident that their followers will believe something is a scientific paper if they just make it look like a scientific paper; but most of all,
  • Contempt for the obligations they owe their followers: they have no compunction about tricking them into risking the lives of their babies by using mendacious means to convince them of homebirth safety.
Saraswathi Vedam's Homebirth: An Annotated Guide to the Literature © is a case in point. Vedam has helpfully provided a list of 66 separate citations. But if you read each and every citation, as I have done, you will find that only 3 of the 66 "citations" support the claim that homebirth is as safe as hospital birth.

Vedam was one of the organizers of the recent Homebirth Consensus Summit, a public relations ploy to elevate the status of homebirth midwives, giving the impression that they were "invited to the table" by the expedient of creating the table and issuing all the invitations.

Vedam describes her Guide:
This annotated bibliography provides citations and critical appraisal of original studies on home birth.
It's all very official and "scientific" looking, complete with elaborate subcategories and a table of contents. It's true purpose is betrayed by a statement on the first page:
Please distribute widely.
In other words, it's a document designed for advocacy of homebirth, not truth about homebirth safety. And homebirth advocacy organizations, including Citizens for Midwifery (CfM), the Center for the Childbearing Year, and the Coalition for Improving Maternity Services (CIMS) are duly offering copies of the Guide on their websites.

What does the Guide offer?

Let's start with the title. Reading it, you might think that the guide provides an overview of scientific citations and original scientific research on home birth. You'd be wrong.

Sure, there are some scientific studies in there, but out of 66 total "citations," fully 25, more than 1/3, are not scientific studies at all, 1 was never published and 1 was published in a non-peer reviewed publication.

Well, that's not too bad, is it? Vedam has compiled and annotated a list of 39 studies that "support" homebirth and its safety.

Not exactly.

Of the 39 actual scientific citations:
1 was publicly retracted
17 do not address the issue of homebirth safety.

Okay, so in an effort to support homebirth, Vedam has compiled and annotated 21 contemporary scientific studies that address the issue of homebirth safety. And they show that homebirth is safe, right?

Not exactly.

Of the 21 scientific studies:
2 are underpowered
4 compared homebirth to a hospital group containing high risk women

That leaves 15 studies of which:
12 showed that homebirth had an INCREASED risk of perinatal or neonatal death
3 showed homebirth may be as safe as hospital birth under very strict conditions

That's right. Out of 66 separate citations in Vedam's Guide, only 3 show that homebirth is as safe as hospital birth, 2 from Canada and 1 from the Netherlands. The results from the Dutch study are called into question by the fact that it compared homebirth with a midwife to hospital birth with a midwife. A more recent study showed that low risk birth (home or hospital) with a Dutch midwife has a HIGHER perinatal mortality rate than high risk delivery with a Dutch obstetrician.

Of course, nothing brings the point home like an illustration, such as the view of a typical page of the Guide posted below.



You can view the complete document, with my annotations, here:

Dr. Amy's Annotated Guide to the Annotated Guide

Vedam's deeply disingenous Guide shows how professional homebirth advocates use the forms and language of science to mislead their readers and the contempt that they have both for their readers and for the truth.


This piece first appeared on The Skeptical OB in December 2011.

Friday, July 13, 2012

No wonder Colorado homebirth midwives hid their 2010 death rates



Each year, licensed Colorado homebirth midwives (certified professional midwives, CPMs) are mandated to report their safety statistics. As I detailed in a post about the 2009 statistics, in every year since homebirth midwives were first licensed in 2006, the midwives had a death rate that exceeded the state as a whole (including all races, all gestational ages, all pregnancy complications, all pre-existing medical conditions). Even worse, from 2006 to 2009, the death rate rose dramatically.

Imagine my surprise, therefore, when I looked for the 2010 statistics and learned that the homebirth midwives had failed to released them. Now I know why. They were ever more horrendous than the 2009 statistics.

How did I obtain the 2010 statistics? It's not because the midwives publicly released them. No, they were required to hand them over after a Colorado citizen filed a CORA petition (Colorado Open Records Request). She shared those statistics with me, both the raw data and the summary data complied by the midwives themselves.

I've created a table of mortality rates from 2006-2010.



As you can see, the perinatal death rate for planned homebirth with a licensed Colorado midwife rose from 11.3/1000 in 2009 to an astounding 16.4/1000 in 2010! Compare that to the overall perinatal mortality rate for the entire state of Colorado (all races, all gestational ages, all pregnancy complications, all pre-existing medical conditions) of 6.3/1000.

Colorado homebirth midwives cared for fewer than 1000 patients and managed to lose 15 babies. It is difficult to convey just how appallingly large a number that is. Colorado licensed midwives have a perinatal mortality rate nearly triple that of the state as a whole. That actually dramatically understates the danger of homebirth in Colorado since the correct comparison (if it were available) would be to the mortality rate of low risk white women at term with normal sized babies.

It's easy to understand why Colorado homebirth midwives hid their 2010 statistics; they are an appalling indictment of the midwives and irrefutable evidence that they are unfit and unsafe practitioners.

This is the same tactic being employed on the national level by the Midwives Alliance of North America (MANA). MANA collected death rates for the years 2001-2008. While they were collecting the statistics, they publicly promised they would be used to demonstrate the safety of homebirth midwives, but once they saw the results, they decided to hide them instead.

Now that Colorado homebirth midwives have been licensed for 5 years and had appalling and RISING death rates over that period, it is time to acknowledge the obvious. Licensed homebirth practitioners are grossly incompetent. They lack the education and training required of ALL other midwives in Europe, Canada and Australia and required of US nurse midwives (CNMs). It is time to end the experiment and declare it a resounding failure.

Homebirth in Colorado (and everywhere else in the US) is not about babies, and it is not about birth. It is about a bunch of high school graduates who couldn't or wouldn't get real midwifery training and made up a pretend credential they award to themselves to fool an unsuspecting public.

Colorado homebirth midwives are unethical in the worst possible way; they don't care how many newborn lives are sacrificed, indeed that will go to great lengths to hide how many newborn lives are lost, in an effort to continue collecting fees for appallingly incompetent care. Of course, they are merely copying the behavior of their national leaders. The entire leadership of American homebirth, from the President of MANA on down should be ashamed of themselves.

How do American homebirth midwives handle their mistakes? They bury them --- both literally and figuratively.


This piece first appeared on The Skeptical OB in June 2012.

Uterine rupture: how much time do you have to save the baby?



A new study to be published in the April issue of Obstetrics and Gynecology demonstrates that in the wake of a uterine rupture, providers have no more than 18 minutes to deliver the baby before the baby experiences significant hypoxia, and only 30 minutes until the baby suffers major neurological impairment.

The paper, entitled Uterine Rupture With Attempted Vaginal Birth After Cesarean Delivery: Decision-to-Delivery Time and Neonatal Outcome by Calla Holmgren et al. was undertaken to provide the most accurate information possible about the conditions needed to make attempted vaginal birth after cesarean (VBAC) as safe as possible.

The authors note:

The increasing rate of primary and repeat cesarean delivery in the United States is of concern to physicians and patients, and vaginal birth after cesarean delivery is considered to be one way to lower the overall cesarean delivery rate. Trial of labor after cesarean delivery (TOLAC), which peaked at 31% in 1998, has decreased progressively since (8.5% by 2006), primarily because of issues surrounding uterine rupture. Although rupture of the uterus during TOLAC is rare, it can be devastating for both the mother and neonate when it occurs, and it is a major liability risk for physicians. The American College of Obstetricians and Gynecologists’ guidelines advise physicians that TOLAC is most safely undertaken in hospitals where staff can immediately carry out an emergency cesarean delivery. This view is based on the premise that the ability to rapidly intervene will minimize adverse neonatal outcomes. However, immediate availability is loosely defined, and it is not clear how rapidly the fetus must be delivered after uterine rupture to prevent neonatal death or neurologic sequelae. The purpose of this study was to examine whether an association exists between neonatal outcomes and the time from diagnosis of uterine rupture to delivery of the neonate.
In other words, should hospitals refuse a trial of labor to women with a previous C-section if they cannot guarantee that both an obstetrician and and anesthesiologist are on site to start a C-section with less than a half hour?

What did they look for?
The primary adverse outcome was defined as an abnormal umbilical pH level less than 7.0 or a 5-minute Apgar score of 7 or less. Secondary adverse outcomes included fetal or early neonatal death and neonatal neurologic injury attributed to uterine rupture. Neonatal neurologic injury was defined as otherwise unexplained seizures, clinically obvious cerebral palsy, or developmental delay attributable to hypoxia resulting from the uterine rupture.
Who was included in the study?
Within the 10 hospitals studied, 40,772 women were identified with a prior cesarean delivery between January 1, 2000, through December 31, 2009. Of these, 11,195 women (27.5%) attempted TOLAC, with successful vaginal delivery for 9,419 (84.1%) patients... In total, there were 36 cases of documented uterine rupture (0.32%) during TOLAC.
What did they find?
Of the 36 patients, 13 (36.1%) met our criteria for a primary adverse outcome of umbilical artery pH level less than 7.0 or 5-minute Apgar score less than 7. These patients were compared with the 23 patients without this outcome. Median (range) time to delivery for the primary adverse outcome group (n=13) was 19 (9–40) minutes compared with 14 (0 –38) for the nonadverse outcome group. Results after stratifying the sample by hospital type yield a similar result, with those experiencing the primary outcome having, on average, a 5.5-minute (95% confidence interval [CI] 0.0 –15.0) longer time to delivery than those who did not experience the outcome...

Seventeen neonates (47.2%) were delivered less than 18 minutes after identification of uterine rupture. Of these, two neonates had an abnormal 5-minute Apgar score, but both of these neonates had an umbilical pH level greater than 7.0 and none had neurologic injury. Eighteen patients were delivered more than 18 minutes after suspicion of uterine rupture (50.0%). Of these, 11 met criteria for a primary adverse outcome and three met criteria for an adverse secondary outcome. One patient did not have suspected uterine rupture during labor.



Seventeen neonates (47.2%) were delivered less than 18 minutes after identification of uterine rupture. Of these, two neonates had an abnormal 5-minute Apgar score, but both of these neonates had an umbilical pH level greater than 7.0 and none had neurologic injury. Eighteen patients were delivered more than 18 minutes after suspicion of uterine rupture (50.0%). Of these, 11 met criteria for a primary adverse outcome and three met criteria for an adverse secondary outcome. One patient did not have suspected uterine rupture during labor.
A chart of the data makes the relationship between time to delivery and risk of adverse outcomes quite clear.



More than 83% of babies delivered more than 30 minutes after uterine rupture experienced major neurological complications.

As the authors explain:
Our study focused on serious neurologic morbidity in cases of confirmed uterine rupture during TOLAC. In 36 cases of acute uterine rupture, there were no fetal or neonatal deaths. Delivery within less than 18 minutes was associated with adverse primary outcome in two cases, but this was based on a 5-minute Apgar score less than 7; both neonates had normal umbilical pH levels. Three neonates in our study sustained long-term neurologic damage. These neonates were delivered 31, 40, and 42 minutes after uterine rupture was suspected on clinical grounds. When uterine rupture was identified in a timely fashion and delivery occurred in less than 30 minutes, there was no long-term neonatal morbidity in our study. However, delivery within 30 minutes did not prevent every case of low umbilical cord pH level or low 5-minute Apgar score, so these results should be interpreted with caution...
The authors conclude:
Uterine rupture during TOLAC is a rare but serious complication that requires prompt recognition and delivery of the fetus. The response time necessary to prevent neonatal injury has been uncertain and controversial. In our study, all neonates delivered within 18 minutes from decision to delivery had normal umbilical cord pH levels. Delivery within 30 minutes was associated with good long-term outcomes...
This is an important study that has the potential for wide impact. The study strongly confirms the ACOG recommendation that babies should be delivered as soon as possible in the wake of a uterine rupture. Intervals longer than 18 minutes resulted in demonstrable hypoxia and intervals longer than 30 minutes resulted in major neurological impairment. Studies like these make it extremely unlikely that hospitals and malpractice insurers will liberalize access to VBAC.


This piece first appeared on The Skeptical OB in March 2012.

International comparisons of neonatal and infant mortality are invalid



The annual meeting of the Society for Maternal-Fetal Medicine is currently being held in Dallas. Two different papers will be presented today, both of which highlight the increased risks of homebirth.

The first is Neonatal outcomes associated with intended place of birth: birth centers and home birth compared to hospitals (abstract 65) by Cheng, Snowden and Caughey. According to the authors:

This was a retrospective cohort study of singleton live births that occurred in 2008 in the U.S. that had specified birthing facility information. Deliveries were categorized by location of occurrence: hospitals, birthing centers, or intended home births...
What did they find?
While the risk of cesarean delivery was much lower for women who delivered/or intend to deliver outside of hospitals (0.02-4% vs. 24%, <0.001), the odds of 5-minute Apgar score <7 and neonatal seizure was significantly higher for intended home births compared to hospital birth.


In other words, while homebirth has a dramatically lower C-section rate, the price is double to triple the rate of birth asphyxia. This study actually substantially underestimates the risk of these serious complications at homebirth because it compares homebirth to all risk hospital birth instead of low risk hospital birth.

The second study is entitled Does planned home birth affect neonatal mortality? (abstract 563) by Joel Larma.
This is a population based retrospective cohort study of all births between 37 and 42 weeks gestation using the National Health Center for Vital Statistics 2005 Linked Birth/Infant Death Cohort Data Set. The primary outcome was neonatal mortality and the primary predictor was planned home birth. The referent group for the regression model was births that occurred in a hospital...
The authors did not separate homebirths attended by CNMs from homebirths attended by non-nurse midwives. The analysis showed that homebirth more than doubled the risk of neonatal death. This actually underestimates the risk because it compares homebirth to term hospital birth in women without pre-existing medical conditions, but apparently includes hospital births with pregnancy complications.
The adjusted OR for neonatal mortality among individuals having a planned home birth was 2.32 (95% CI 1.33, 4.06) after controlling for the aforementioned covariates [age, race, marital status, education, prenatal care, tobacco use, composite medical comorbidities].

CONCLUSION: The odds of neonatal mortality are significantly increased among those individuals having a planned home birth compared to those individuals giving birth in the hospital.
The amount of data on planned homebirth is slowly growing and the findings are remarkably robust. These studies, like all the existing scientific evidence, state and national statistics show that homebirth doubles or triples the rate of neonatal death and other adverse outcomes, and that the analyses almost certainly underestimate the real increased risks at homebirth.


addendum: These studies underestimate the risk even further because, as far as I can determine, bad outcomes that occurred after homebirth transfer are included in the hospital group and removed from the homebirth group. The real number of bad outcomes and deaths is higher than what the authors were able to determine.


This piece first appeared on The Skeptical OB in March 2012.

Two new studies show increased risk of death, serious complications at homebirth



The annual meeting of the Society for Maternal-Fetal Medicine is currently being held in Dallas. Two different papers will be presented today, both of which highlight the increased risks of homebirth.

The first is Neonatal outcomes associated with intended place of birth: birth centers and home birth compared to hospitals (abstract 65) by Cheng, Snowden and Caughey. According to the authors:

This was a retrospective cohort study of singleton live births that occurred in 2008 in the U.S. that had specified birthing facility information. Deliveries were categorized by location of occurrence: hospitals, birthing centers, or intended home births...
What did they find?
While the risk of cesarean delivery was much lower for women who delivered/or intend to deliver outside of hospitals (0.02-4% vs. 24%, <0.001), the odds of 5-minute Apgar score <7 and neonatal seizure was significantly higher for intended home births compared to hospital birth.


In other words, while homebirth has a dramatically lower C-section rate, the price is double to triple the rate of birth asphyxia. This study actually substantially underestimates the risk of these serious complications at homebirth because it compares homebirth to all risk hospital birth instead of low risk hospital birth.

The second study is entitled Does planned home birth affect neonatal mortality? (abstract 563) by Joel Larma.
This is a population based retrospective cohort study of all births between 37 and 42 weeks gestation using the National Health Center for Vital Statistics 2005 Linked Birth/Infant Death Cohort Data Set. The primary outcome was neonatal mortality and the primary predictor was planned home birth. The referent group for the regression model was births that occurred in a hospital...
The authors did not separate homebirths attended by CNMs from homebirths attended by non-nurse midwives. The analysis showed that homebirth more than doubled the risk of neonatal death. This actually underestimates the risk because it compares homebirth to term hospital birth in women without pre-existing medical conditions, but apparently includes hospital births with pregnancy complications.
The adjusted OR for neonatal mortality among individuals having a planned home birth was 2.32 (95% CI 1.33, 4.06) after controlling for the aforementioned covariates [age, race, marital status, education, prenatal care, tobacco use, composite medical comorbidities].

CONCLUSION: The odds of neonatal mortality are significantly increased among those individuals having a planned home birth compared to those individuals giving birth in the hospital.
The amount of data on planned homebirth is slowly growing and the findings are remarkably robust. These studies, like all the existing scientific evidence, state and national statistics show that homebirth doubles or triples the rate of neonatal death and other adverse outcomes, and that the analyses almost certainly underestimate the real increased risks at homebirth.


addendum: These studies underestimate the risk even further because, as far as I can determine, bad outcomes that occurred after homebirth transfer are included in the hospital group and removed from the homebirth group. The real number of bad outcomes and deaths is higher than what the authors were able to determine.


This piece first appeared on The Skeptical OB in February 2012.

The death toll of California homebirth



The state of California has released a comprehensive summary of outcomes of California licensed homebirth midwives of the year 2010. The reports makes for disturbing reading. Homebirths exceed low risk (and sometimes high risk) hospital birth on almost every negative outcome including deaths.

Before we look at the outcomes, let's look at whether California licensed homebirth midwives comply with their own rules.

The first thing to note is that although all midwives are required to report outcome statistics, 16% never bothered to report their outcomes.

The second is that midwives are required to consult with and generally transfer care to obstetricians if a baby is known to be breech or in the case of twins. Nonetheless, California midwives delivered 13 breech babies and 5 sets of twins at home.

Let's look at the basic statistics.

There were 2245 who planned homebirths at the onset of labor. 1840 delivered at home, for a transfer rate of 18%. There were 205 C-sections for a C-section rate of 9.1%.

How about outcomes? Simply put, the outcomes are dreadful as the chart below demonstrates.



The fetal mortality rate was 11/1000 compared to the California rate for white women (all gestational ages, all pre-existing medical conditions, all pregnancy complications) of 4.9/1000 for a rate more than double that expected.

The intrapartum mortality rate was 2.6/1000 compared to the expected rate of 0.3/1000, for a rate more than 8 times higher than expected.

The neonatal mortality rate was 0.9/1000 compared to the national rate for low risk white women of 0.4/1000, for a neonatal mortality rate more than double that expected.

A perinatal mortality rate of 12/1000 compared to the California rate for white women (all gestational ages, all pre-existing medical conditions, all pregnancy complications) of 5/1000 for a rate more than double that expected.

These numbers potentially under-count the real death rates for 2 reasons. First, among reported perinatal outcomes after transfer 11 were classified as unknown. Second, fully 16% of California homebirth midwives failed to report their outcomes.

How about birth complications? There were quite a few considering that the mothers were extremely low risk.

maternal

4 cases of massive PPH
1 case of seizure/shock
10 cases of retained placenta

neonatal

1 case of birth injury
2 cases of abnormal cry/seizures/loss of consciousness
6 cases of clinically apparent infection
9 cases of significant cardiac of respiratory issues
3 cases of 5 minute Apgar less than 6

Untimately, 14 mothers suffered serious complications resolved by 6 weeks and 1 mother suffered serious complications that persisted beyond 6 weeks. 21 infants suffered serious complications resolved by 6 weeks and 4 suffered serious complications that persisted beyond 6 weeks.

What conclusions can we draw from this data?

First and most important, despite the fact that the homebirth population presumably represents the lowest of low risk patients, the neonatal death rate is double that expected for low risk white women. The overall perinatal mortality rate is double that for all white women in California (including premature births, all pre-existing medical conditions, and all complications of pregnancy).

Second, homebirth in California has an extraordinarily high rate of intrapartum death, more than 8 times higher than the intrapartum death rate for women of all races, all gestational ages, all pre-existing medical conditions and all complications of pregnancy. While rigorous intermittent auscultation might be equivalent to electronic fetal monitoring under experimental conditions, that is clearly not true of intermittent auscultation as practiced by California homebirth midwives. In a population this size, we would expect that every woman who enters labor with a live baby will deliver a live baby. Instead, 6 babies died in the course of labor, because midwives didn't recognize fetal distress and/or didn't transfer in a timely fashion if they did recognize it.

Third, these results probably underestimate the dangers of homebirth in California because a substantial proportion of information is missing.

The bottom line is that homebirth in California increases the risk of perinatal and neonatal death by 100% or more. California homebirth midwives, like all homebirth midwives, "trust birth" and birth, far from being trustworthy, is inherently dangerous.


California birth outcomes can be found here.
For more information on the source of the homebirth statistics: Licensed Midwife Annual Report user guide.


addendum: Ideally, the California homebirth statistics should be compared to the mortality rates for California women in 2010 without any of the following risk factors (in order of importance): African descent, prematurity, pre-existing medical conditions and pregnancy complications that occur before onset of labor. Unfortunately, the mortality rate of that group is unavailable, so each comparison is made with the available group having the least number of risk factors.

In the case of neonatal mortality, the comparison group is hospital birth for low risk white women at term for 2007; for intrapartum mortality the only available group is all women; for fetal mortality the best available group is California white women of 2009; similarly for perinatal mortality the best available group is California white women of 2009.

Practically speaking, the substitution of these groups means that in all cases besides neonatal mortality, the correct comparison group would have much smaller mortality rates and that, therefore, the real increased risk of homebirth is much higher than that depicted here.

It is also important to note that homebirth appears to be associated with dramatically higher rates of intrapartum mortality, a vanishingly rare event among low risk women at term. Therefore, the figures that I routinely quote demonstrating that homebirth has a neonatal mortality rate at least 3 times higher than comparable risk hospital birth, dramatically underestimate the true risk.


This piece first appeared on The Skeptical OB in February 2012.

Near-miss maternal mortality



Maternal mortality has dropped 99% in the past 100 years. A maternal death is now, fortunately, a rare event. Attention, therefore, is shifting to maternal morbidity, in particular, life-threatening morbidity. The results of a new study are instructive.

Near-Miss Maternal Mortality: Cardiac Dysfunction as the Principal Cause of Obstetric Intensive Care Unit Admissions by Small et al. will be published in the February 2012 issue of Obstetrics and Gynecology. The title gives away the principle finding; heart disease is the most common cause of maternal ICU admission.

The study took place at Duke University from January 2005 to April 2011. There were 19,575 births and 5 maternal deaths for a maternal mortality rate of 25/100,000. That is approximately double the US maternal mortality rate, but that is only to be expected in a tertiary center that receives the most complicated cases from the surrounding area. There causes of the five maternal deaths were: two from metastatic cancer, two secondary to cystic fibrosis, and one the result of sepsis.

The authors then looked at maternal admissions to the intensive care unit:

Ninety-four obstetric patients—five per 1,000 deliveries—were admitted to ICUs. Eight declined participation in the study. Eighty-six patients were included in this analysis.

... African American women comprised the largest population admitted to the ICU (45%). Significant differences were found by race and ethnicity in the following variables: parity, BMI, and marital and insurance status. African American (mean 35) and Hispanic women (mean 36) had significantly higher BMIs than white women (mean 28). African American and Hispanic women were also more likely to have Medicaid or no insurance and were more likely to be unmarried and multiparous.
The following table shows the reasons for ICU admission.



The authors write:
... The leading admission diagnosis for pregnant and postpartum women was maternal cardiac disease (36%). Maternal hemorrhage (both obstetric and nonobstetric) was the second leading reason for admission (29%). Hypertensive disease accounted for 9% of ICU admissions...

The majority of cardiac conditions prompting ICU admission resulted from cardiomyopathy. Acute complications associated with peripartum cardiomyopathy
comprised the majority of this group. Congenital heart disease is the underlying etiology for many of these valvular lesions and cardiomyopathies. Congenitally
acquired conditions were the second leading cause of maternal cardiac ICU admissions...
The findings of this study are notable for the following:
  1. Race is a major risk factor for near-miss maternal mortality.
  2. Obesity (BMI greater than 30) is a major risk factor for near-miss mortality.
  3. The leading cause of near-miss mortality is cardiac disease.
  4. Infection and bleeding account for only one third of the near-miss events.
This paper demonstrates that near miss-maternal mortality, like maternal mortality, is the result of complex medical and non-medical factors. Both race and maternal BMI appear to play important roles. Pre-existing medical conditions account for a substantial proportion of near-miss maternal mortality. The traditional causes of maternal mortality and near-miss mortality have been eclipsed by cardiac complications of pregnancy.

In other words, contrary to the claims of natural childbirth and homebirth advocates, maternal mortality and near-miss maternal mortality are not related to obstetric interventions. The most common risk factor is pre-existing maternal health issues. Women with serious medical problems (including obesity) prior to pregnancy are the ones most likely to develop life threatening medical problems during pregnancy and childbirth.


This piece first appeared on The Skeptical OB in January 2012.

2011 ends with 5th North Carolina homebirth death



Sadly, 2011 ended with an appalling 5th confirmed homebirth death in North Carolina. The fourth homebirth death had actually occurred several days later. The death was, as is typically the case with homebirth deaths, needless, senseless, utterly predictable, and totally preventable.

The mother is a doula and had a waterbirth. The baby was a breech with a trapped head. The mother transferred to the hospital with the breech suspended from her vagina. By the time doctors could extricate the baby, she was dead.

This brings the confirmed homebirth death rate in North Carolina in 2011 to an extraordinary 12X times the expected death rate for comparable risk hospital birth (0.4/1000), and proves, yet again, that breech is NOT a variation of normal.

How many babies have to die before homebirth advocates realize that "trusting" birth is a recipe for disaster?


This piece first appeared on The Skeptical OB in January 2012.

Latest CDC data: homebirth killing more babies than ever



In 2003 the US standard birth certificate form was revised to include place of birth and attendant at birth. That makes it possible to compare neonatal death rates at home vs. in the hospital. The first data set (2003-2004) showed that homebirth had triple the rate of neonatal mortality as comparable risk hospital birth. The most recent data set shows was recently released by CDC Wonder and the results are appalling:

In 2007, American homebirth with a homebirth (non-CNM) midwife had a neonatal mortality rate 7.7 times higher than comparable risk hospital birth!



The table shows that the neonatal mortality rate for homebirths attended by an American homebirth midwives (CPM, LM) is 7.7 time higher than comparable risk hospital birth attended by a CNM (certified nurse midwife). This extraordinarily high death rate is all the more remarkable because it actually under-counts the homebirth death rate. That's because homebirth transfers ended up in the hospital MD group and were not counted in the homebirth group. The real number of homebirth deaths is almost certainly significantly higher.

No wonder the Midwives Alliance of North American (MANA) continues to hide their death rates. How many of the 24,000 babies in their database of outcomes from 2001-2008 died at the hands of homebirth midwives? They won't say, but the rate is probably comparable to, or perhaps even higher than this extraordinarily high rate.

Homebirth advocates having been crowing that the rate of homebirth has risen 20% from the early to late 2000's, but the death rate, which was already unacceptably high, appears to have risen, too.

Homebirth with an American homebirth midwife kills babies. There is simply no question about it. Even the Midwives Alliance of North America knows that this is true. It's time that American homebirth advocates stopped lying about the safety of homebirth and start doing something to reduce the number of preventable neonatal deaths.


This piece first appeared on The Skeptical OB in December 2011.

The UK Birthplace Study: homebirth increases the risk of death



The largest, most comprehensive study ever done of homebirth has released its results and there's nothing left to argue about: homebirth increases the risk of perinatal death.

The Birthplace Study, a large multi-year study, was designed to address the safety of place of birth by controlling for the many factors that had not been handled properly in other studies. The study looked at intended place of birth to rule out improperly assigning transferred patients to the hospital group, and included only the lowest possible risk women. The study was conducted by The National Perinatal Epidemiology Unit in the United Kingdom.

The authors found that homebirth increases the risk of death, brain damage and serious neonatal injury.

The authors chose to evaluate the results by creating an index of primary events comprising intrapartum stillbirths, early neonatal deaths, neonatal encephalopathy [brain damage] meconium aspiration syndrome, brachial plexus injury, and fractured humerus or clavicle. Using this measurement:

... [T]here was a significant excess of the primary outcome in births planned at home compared with those planned in obstetric units in the restricted group of women without complicating conditions at the start of care in labour. In the subgroup analysis stratified by parity, there was an increased incidence of the primary outcome for nulliparous women in the planned home birth group (weighted incidence 9.3 per 1000 births, 95% confidence interval 6.5 to 13.1) compared with the obstetric unit group (weighted incidence 5.3, 3.9 to 7.3).
In other words, the risk of death and serious injury was approximately double in the homebirth group and that increase was seen mainly among first time mothers.

The authors did not include the number and distribution of specific primary events within the paper itself, but did publish a 78 page supplementary file including this information. The following tables are adapted from that file. (OU stands for Obstetric unit [hospital], AMU stands for along side maternity unit [in hospital birth center], and FMU for free-standing maternity unit [independent birth center].)

Stillbirths



Early neonatal deaths (to 7 days)



Encephalopathy [brain damage]



The authors put the best possible face on the outcome:
... Adverse perinatal outcomes are uncommon in all settings, while interventions during labour and birth are much less common for births planned in non-obstetric unit settings. For nulliparous women, there is some evidence that planning birth at home is associated with a higher risk of an adverse perinatal outcome...
What can we conclude?

Homebirth increases the risk of perinatal death and brain damage in the lowest risk women receiving care from highly trained midwives (often two) and liberal access to transfer.

Homebirth increases the risk of perinatal death and brain damage even when, at the start of labor, breech, twins, VBAC. positive GBS status, gestational diabetes and obesity were excluded. All routinely occur at homebirths in the US, the UK and Australia.

And how about the purported "risks" of interventions that homebirth advocates are always taking about?

Homebirth increases the risk of perinatal death and brain damage even though the incidence of epidural use was 5 times higher in the hospital group.

Homebirth increases the risk of perinatal death and brain damage even though the incidence of pitocin augmentation was 5 times higher in the hospital group.

Homebirth increases the risk of perinatal death and brain damage even though the incidence of operative vaginal delivery was 3-4 times higher in the hospital group.

Homebirth increases the risk of perinatal death and brain damage even though the C-section rate was 4 times higher in the hospital group.

In other words, any way you choose to look at it, no matter how carefully you slice and dice the data, there is simply no getting around the fact that homebirth increases the risk of perinatal death and brain damage.


This piece first appeared on The Skeptical OB in November 2011.

New Zealand study tries to buy increased homebirth death rate



No wonder Melissa Cheyney refuses to release the death rate of Oregon homebirths.

In August, I wrote:

The minutes of the August 5, 2010 Board meeting reports that the state of Oregon asked for the ability to retrieve information on Oregon midwives from the database:

"Cheyney stated that the MANA board's official policy is to give state-level accounts to professional organizations as a tool to evaluate areas where more training might be needed for the purpose of self regulation, and to not provide the data to regulatory entities."

In other words, the database is only to be used by MANA itself, and not shared with anyone who could potentially identify unqualified midwives and discipline them.
It doesn't take a rocket scientist to speculate that there have been an extraordinary number of deaths. Now comes information from a new source that confirms that suspicion.

A new website, Oregon Homebirth Midwife Info, has compiled a Midwife Directory that makes for stomach-churning reading. The directory lists midwives by name and includes reports of deaths as well as other major morbidity and actions taken against the midwives.

It is an incomplete list; not all Oregon midwives are included and there may have been additional deaths that are not recorded. Nonetheless, the statistics are no less than horrifying.

In the past decade, no less than 19 babies have died at the hands of Oregon homebirth midwives.

To put that in perspective, consider that there are approximately 1000 homebirths per year in Oregon and that the neonatal death rate for low risk women in a hospital setting is 4/10,000 (0.4/1000). That means that you would expect approximately 4 homebirth deaths per decade. Instead there were at least 19 deaths, for a rate more than 4X higher (375%) than expected.

No less than 16 midwives have presided over at least one death. Interestingly, only 2 were unlicensed midwives. The rest were licensed at the time of the death(s) and almost all had complaints filed against them with the Board of Direct Entry Midwifery. In other words, this information is available to Melissa Cheyney in her role as a member of the Board.

Homebirth kills babies. No one knows that better than Melissa Cheyney, who has, until now, successfully hidden the number of homebirth deaths at the hands of Oregon homebirth midwives, and who continues, in her role as Director of Research at MANA (Midwives Alliance of North America), to hide the number of babies who died at the hands of homebirth midwives across the country.


This piece first appeared on The Skeptical OB in November 2011.

How many babies died at the hands of Oregon homebirth midwives?



No wonder Melissa Cheyney refuses to release the death rate of Oregon homebirths.

In August, I wrote:

The minutes of the August 5, 2010 Board meeting reports that the state of Oregon asked for the ability to retrieve information on Oregon midwives from the database:

"Cheyney stated that the MANA board's official policy is to give state-level accounts to professional organizations as a tool to evaluate areas where more training might be needed for the purpose of self regulation, and to not provide the data to regulatory entities."

In other words, the database is only to be used by MANA itself, and not shared with anyone who could potentially identify unqualified midwives and discipline them.
It doesn't take a rocket scientist to speculate that there have been an extraordinary number of deaths. Now comes information from a new source that confirms that suspicion.

A new website, Oregon Homebirth Midwife Info, has compiled a Midwife Directory that makes for stomach-churning reading. The directory lists midwives by name and includes reports of deaths as well as other major morbidity and actions taken against the midwives.

It is an incomplete list; not all Oregon midwives are included and there may have been additional deaths that are not recorded. Nonetheless, the statistics are no less than horrifying.

In the past decade, no less than 19 babies have died at the hands of Oregon homebirth midwives.

To put that in perspective, consider that there are approximately 1000 homebirths per year in Oregon and that the neonatal death rate for low risk women in a hospital setting is 4/10,000 (0.4/1000). That means that you would expect approximately 4 homebirth deaths per decade. Instead there were at least 19 deaths, for a rate more than 4X higher (375%) than expected.

No less than 16 midwives have presided over at least one death. Interestingly, only 2 were unlicensed midwives. The rest were licensed at the time of the death(s) and almost all had complaints filed against them with the Board of Direct Entry Midwifery. In other words, this information is available to Melissa Cheyney in her role as a member of the Board.

Homebirth kills babies. No one knows that better than Melissa Cheyney, who has, until now, successfully hidden the number of homebirth deaths at the hands of Oregon homebirth midwives, and who continues, in her role as Director of Research at MANA (Midwives Alliance of North America), to hide the number of babies who died at the hands of homebirth midwives across the country.


This piece first appeared in The Skeptical OB in November 2011.

Reducing early elective delivery leads to more deaths



You could have seen this coming.

In a flourish of righteous zeal, the March of Dimes went on record strongly opposing early elective delivery before 39 weeks gestation. They railed against the increase in NICU admissions; they railed against the increase in C-sections; and they railed against the increase in costs. What they inexplicably failed to take into account was the inevitable increase in stillbirths.

When the Christiana Care Health System in Delaware implemented the March of Dimes recommendations, NICU admissions decreased, C-section rates decreased and cost decreased. And more babies died.

Neonatal Outcomes After Implementation of Guidelines Limiting Elective Delivery Before 39 Weeks of Gestation by Ehrenthal et al published in the forthcoming issue of the journal Obstetrics and Gynecology looked at neonatal outcomes before and after limiting elective delivery prior to 39 weeks of gestation.

All singleton deliveries 37 or more completed gestational weeks during the periods of interest were included. Any fetal death was considered a stillbirth; all others were considered live births and were analyzed separately. Each stillbirth was verified and cause of death determined by review of the hospital medical record by the study investigators...

We assessed change in obstetric practice by determining the percentage of neonates delivered during the early term if the delivery was at 37 or 38 weeks compared with full term if the delivery was 39 or more completed weeks...

We had three primary neonatal outcomes for this study: admission to the NICU for at least 24 hours, fetal macrosomia, and stillbirth...
What did they find?

The new policy achieved the objective of lowering births prior to 39 completed weeks gestation:
... the overall percentage of deliveries during the early term fell from 33.1% to 26.4% (P<.001) after the guidelines were introduced when compared with before. This changed for the cohort overall and for both cesarean and vaginal deliveries. The magnitude of the change was greater for those women with an induced labor and repeat cesarean delivery; the change was greatest for those undergoing an electively induction of labor...
NICU admissions dropped:
The overall rate of admission to the NICU was significantly different between the two periods; before the intervention, there were 1,116 admissions (9.29% of term live births), whereas after, there were 1,027 (8.55% of term live births) and this difference was significant (P=.044). Multivariable logistic regression revealed a reduced odds of a NICU admission (adjusted OR 0.92, 95% CI 0.84–1.01) after the intervention...
But the stillbirth rate more than tripled:
... The overall rate of stillbirth of nonanomalous fetuses differed between the periods with an overall increased risk of stillbirth after the intervention (relative risk 2.14, 95% CI 0.87–5.26, P=.06); this overall increase was not statistically significant. However, stratification by gestational age group of the stillbirth revealed the increased risk in the after group was limited to stillbirths before 39 weeks, which increased from 2.5 to 9.1 per 10,000 term pregnancies (relative risk 3.67, 95% CI 1.02–13.15, P=.032), whereas there was no change in risk of stillbirth at 39 weeks or more (relative risk 0.91, 95% CI 0.23–3.64, P=.896).
Because this increase in stillbirths is so large, the authors reviewed each stillbirth to be sure that they were not the result of risk factors that would have triggered a medically indicated induction.
The authors carefully reviewed the medical records of each stillbirth to identify cause of death and the presence of a maternal risk factor ... No definitive cause-of-death pattern emerged.
The reduction in early elective delivery achieved the aims for which the March of Dimes advocated. The reduction in early elective delivery reduced NICU admissions, reduced both the induction rate and the C-section rate, and (although the authors did not measure this) presumably reduced costs. However, these benefits were achieved at a very steep price. The stillbirth rate increased from 2.5 to 9.1 per 10,000 term pregnancies. Instead of 3 stillbirths between 37-39 weeks among 12,000 patients, there were 11 stillbirths between 37-39 weeks among a similar number of patients after reduction in early elective deliveries.

This finding is not unexpected. CDC data shows that the stillbirth rate rises from approximately 3 per 10,000 at 37 weeks to 4.5 per 10,000 at 39 weeks. An increase of 6 stillbirths in a population of 12,000 women is almost exactly what you would expect from reducing deliveries between 37-39 weeks.

This brings us to the heart of the matter. We have traditionally approached the inherent dangers of childbirth by attempting to reduce perinatal mortality. Our efforts have been so successful, that we have turned our attention to reducing perinatal morbidity under the assumption that any reduction in morbidity would be added on to the existing reductions in mortality.

That assumption in clearly not justified. That's because low rates of perinatal mortality have been achieved, in part, by exchanging mortality for morbidity. There are fewer deaths when you deliver babies before 37-39 weeks (whether for indicated or elective reasons); those babies who otherwise would not have lived experience relatively mild, self limited problems related to borderline prematurity. Attempts to reduce these morbidities by preventing borderline premature delivery may simply result in the deaths of these babies, not an overall improvement in outcomes. That's certainly what the existing data on stillbirths and gestational age would predict and that's precisely what happened in this study.


This piece first appeared on The Skeptical OB in October 2011.

New Dutch study raises troubling questions about the safety of homebirth



A new Dutch study of homebirth appears in the forthcoming issue of the journal Obstetrics and Gynecology. Planned Home Compared With Planned Hospital Births in The Netherlands by van der Kooy et al. is large, comprehensive and raises troubling questions about the safety of homebirth.

The large amount of data is analyzed in a bewildering number of ways, but the bottom line is that homebirth is safe when nothing goes wrong; in the presence of life threatening problems, homebirth increases the risk of death. Moreover, while homebirth with a Dutch midwife in the absence of complications is nearly as safe as hospital birth with a Dutch midwife, the perinatal mortality rate in both groups is 33% higher than comparable risk women delivered in hospitals by obstetricians just across the border in Flanders.

This study is one of many undertaken in the Netherlands to investigate the high perinatal mortality rate.

The debate on the safety of home births continues in the literature ... In The Netherlands, approximately 50% of women give birth under the supervision of a community midwife. The community midwives are independent health care professionals in The Netherlands operating either solely or in group practices.

The proportion of home birth deliveries in The Netherlands has steadily decreased over the last decade but is currently stable at 25% of all births. Several Anglo-Saxon countries are considering the reintroduction of home births based on recent claims of sufficient safety. The reverse trend is observed in The Netherlands, where the debate has intensified since the national perinatal mortality rate showed it to be one of the highest in Europe.
The authors started with a very large and comprehensive database, and analyzed it in a variety of ways. They started with 679,952 births: all the low risk births attended by midwives from 2000-2007. They looked at the difference in perinatal death rates (defined restrictively as intrapartum deaths and neonatal deaths up to 7 days of age) between home and hospital birth, first by analyzing what actually happened, then by constructing hypothetical groups of patients, all of whom were ideal candidates for homebirth.
As primary analysis, we present the results of the natural prospective approach resembling an intention- to-treat analysis. For comparison, we added a perfect guideline approach resembling a per-protocol analysis. The natural prospective approach establishes, within observational constraints, the intrapartum and early neonatal death of planned home compared with planned hospital births.
They further analyzed the data by removing deaths due to the "Big 4": congenital anomalies, premature births, intrauterine growth retardation and low Apgar scores. The decision to analyze the data with these deaths removed is baffling. It's baffling because it removes patients who received potentially substandard midwifery care during pregnancy (failure to diagnose anomalies and intrauterine growth retardation as well as failure to appropriately refer patients delivering before term) and it is baffling because it removes babies in need of expert resuscitation. This group is of prime concern when investigating the safety of homebirth because it is this group that faces the greatest risk when born outside the hospital.

Of note, both groups (real-world and hypothetically perfect) differed substantially by maternal characteristics.
Compared with women who planned birth in the hospital or with an unknown location, the women with a planned home birth were more likely to be multiparous, 25 years of age or older, of Dutch origin, and to live in a privileged neighborhood (all of which are favorable conditions). In home birth women, neonatal case mix compared also favorably. Premature delivery was less common as was the prevalence of a Big 4 condition (natural prospective approach home birth 8.7% compared with hospital 10.8% compared with unknown 10.5%; perfect guideline approach home birth 6.5% compared with hospital 8.2% compared with unknown 7.5%, P <001 in both cases).
In other words, the homebirth group was much lower risk than the hospital birth group.

What did the investigators find?
In the natural prospective approach population, crude mortality risk was significantly lower for women who planned to give birth at home (relative risk 0.80, 95% confidence interval [CI] 0.71– 0.91) ... compared with those who intended to give birth in hospital (P <.05). All maternal and neonatal risk factors, except living in a deprived neighborhood, showed significant effect sizes in agreement with the expected direction. Mortality was significantly increased in neonates with a Big 4 outcome, especially in those with multiple Big 4 conditions (relative risk 276.6, 95% CI 240.3–318.3).
When looking at what actually happened, the death rate at home was lower than in the hospital, but that reflects both the difference in risk factors between the two groups and the difference in "Big 4" bad outcomes between the two groups. After adjusting for these risk factors and differences in Big 4 outcomes, home and hospital had similar perinatal mortality rates:
The nested multivariable logistic regression analysis showed that in the presence of adjusting maternal factors only (model 2), the intended place of birth had no significant effect on outcome. The maternal factors showed risks similar to the univariable (crude) analysis. The addition of Big 4 case mix adjustment (model
3) showed the intended place of birth to be a significant covariable, yet the contrast of planned home birth (odds ratio 1.05, 95% CI 0.91–1.21) compared with a hospital birth (reference <1) turned out to be nonsignificant. The effect of maternal risk factors was affected to a limited degree by the introduction of the Big 4 case mix.
The perfect guideline approach yielded similar results.

What does this mean? It means that when nothing goes wrong at homebirth, it is just as safe as midwife attended hospital birth. Since complications are uncommon, the overall rates of homebirth and hospital birth perinatal mortality are very similar. However, in the event of an unanticipated bad outcome, homebirth has a much higher perinatal mortality rate than midwife attended hospital birth.

In a nod to the BMJ study published by their colleagues last year, which showed that low risk birth with a Dutch midwife (home or hospital) has a higher mortality rate than high risk hospital birth with a Dutch obstetrician, the authors acknowledge that the mortality rate for midwife attended births, both home and hospital, are higher than expected:
... The data from an otherwise very similar country such as Flanders suggest that more favorable results may be expected in low-risk women in general from a hospital-based system. In Flanders, perinatal mortality is approximately 33% less than in The Netherlands, whereas the cesarean delivery rates show little difference.
The authors compare their results with other homebirth studies, noting that home and hospital populations differ markedly in risk profile and that any study of homebirth outcomes must correct for these differences.
Our conclusions apparently contradict those of De Jonge et al who concluded equal intrapartum and early neonatal outcome of planned home birth compared with hospital birth in apparently the same population... Our principal approach (natural prospective approach) compares neonatal mortality in the actual populations delivering at home compared with the hospital, whereas the approach of De Jonge et al compares neonatal mortality in a hypothetical group resembling our perfect guideline approach population.
What's the bottom line?

Homebirth is as safe as hospital birth when nothing goes wrong. But when complications occur unexpectedly at birth, hospital is much safer than home.


This piece first appeared on The Skeptical OB in October 2011.

Missouri: homebirth has a 20 fold increase in intrapartum death



The homebirth statistics keep on coming and they keep demonstrating the same thing: homebirth increases the risk of death.

I've written extensively about the appalling rate of perinatal death at the hands of licensed midwives in Colorado, and, of course, the overall US statistics show that homebirth with a direct entry midwife triples the neonatal death rate. The latest data comes from Missouri and the trend continues. Homebirth has a risk of intrapartum death that is more up to 20 times higher than hospital birth.

Birth outcomes of planned home births in Missouri: a population-based study by Chang and Macones published in the American Journal of Perinatology in August 2011 is notable for careful methodology.

... We obtained data from the Missouri live birth and fetal death files that have been linked together by the Missouri Department of Health and Senior Services... The Missouri vital record system is considered very reliable and has been adopted as a "gold standard" to validate other vital statistic datasets in the United States...

Our study sample consisted of women who delivered singleton pregnancies between 36-44 weeks of gestation ... Pregnancies complicated by major fetal anomalies and breech presentation were excluded ...
The authors divided the more than 800,000 births by place of birth and attendant creating three groups: hospital/birth center births attended by physicians and CNMs, homebirths attended by physicians and CNMs and homebirths attended by non-CNM midwives. (Of note, unplanned homebirths and births attended by non-midwives were excluded.) The groups differed significantly by maternal characteristics.
Women who had planned home deliveries attended by either non-CNMs or physicians/CNMs were more likely to be older, to be white, to have more children, to be overweight and to deliver at greater than 41 weeks gestational age, but less likely to be a Medicaid recipient or unmarried, to smoke during pregnancy, or to have a maternal medical risk factor.
Despite this, the outcomes in the homebirth groups (both those managed by non-CNMs and those managed by physicians or CNMs) had much poorer outcomes.
... [W]e observed that rates of newborn seizures were 4 per 1000 births among planned home births attended by non-CNMs, 0.6/1000 among planned home births delivered by physicians/CNMs and 1.1 per 1000 births among deliveries made by physicians/CNMs in hospitals and birthing centers. The rates of intrapartum fetal death were 0.9 per 1000 births among planned homebirths attended by non-CNMs, 1.7/1000 among planned home births delivered by physicians/CNMs, and 0.1 per thousand among deliveries made by physicians/CNMs in hospitals or birthing centers.
Rates of neonatal death were 1.4/1000 among planned homebirths attended by non-CNMs, 0 among planned homebirths attended by physicians/CNMs and 0.6/1000 among hospital/birth center births attended by physicians CNMs. This difference does not reach statistical significance, however.



After the authors employed multivariable logistic regression models:
... We observed that planned home births attended by non-CNMs remained positively associated with odds of newborn seizures after controlling for confounders. Specifically, the adjusted OR of newborn seizure among births delivered by non-CNMs was more than 5 times as much as the odds in hospital/birthing center births delivered by physicians/CNMs ... For intrapartum fetal death, planned home births attended by non-CNMs and physicians/CNM yielded adjusted ORs of 11.24 and 20.33 respectively relative to hospital/birthing center births attended by physicians/CNMs ...


The authors conclude:
Our analysis demonstrates cause of concern about safety of planned home births attended by non-CNMs and physician/CNMs. The results of our study suggest that planned home births are associated with increased likelihood of intrapartum fetal death and newborn seizures, despite the fact that the lowest risk women choose this birthing option.
As is the case with most homebirth studies, this study could not separate out home birth transfers from the hospital birth group. Therefore, the study likely underestimates the magnitude of the increase risk posed by homebirth.


This piece first appeared on The Skeptical OB in October 2011.

S. Australia: Homebirth death rate 17 times higher than comparable risk hospital birth



The state of South Australia, which includes the city of Adelaide, has published it's perinatal mortality rates. The data shows that planned homebirth has a perinatal mortality rate more than 17X higher than comparable risk hospital birth.

The report, Pregnancy Outcome in South Australia 2009, is a dry recitation of birth statistics without editorial comment. The statistics are analyzed in every possible way to give a vivid picture of birth in the state. Among the ways the data is analyzed is according to place of birth and the results are surprising and distressing.





Any way you look at it, planned homebirth has a dramatically higher rate of death. The stillbirth rate is higher; the neonatal mortality rate is higher; and therefore, the perinatal mortality rate is higher. In fact, the perinatal mortality rate is more than 17 times higher than that at comparable risk hospital birth! These findings are even worse than the appalling findings from Western Australia, where the data showed that homebirth tripled the rate of perinatal death.

Surprisingly, the perinatal death rate at birth centers was also far higher than the rate at comparable risk hospital birth. Birth centers had a perinatal mortality rate 5X comparable risk hospital birth. This is completely unexpected. Birth centers should have a perinatal mortality rate lower than hospital birth because women with preexisting medical conditions and serious pregnancy complications are concentrated in the hospital group.

Since there were only a relatively small number of planned homebirths, the exact magnitude of the risk is probably smaller than 17 fold. However, the increased risk of perinatal and neonatal death is a remarkably robust finding, extending across time periods and countries and states. To my knowledge, all the existing international, national and state statistics show that homebirth increases the perinatal and neonatal death rates by at least a factor of 3. There is only one exception, a single paper out of Canada; the paper is notable for very strict homebirth criteria and a high transfer rate of greater than 20% in the homebirth group.

There is really no question that homebirth increases the risk of perinatal death. The only people who appear to be unaware of this are homebirth advocates themselves.


This piece first appeared on The Skeptical OB in October 2011.

US newborn death rate tied with Qatar? Not exactly.



Professional homebirth advocates routinely trick their followers by preying on their gullibility and lack of basic knowledge of science, statistics and obstetrics.

Consider the following statements:

Ricki Lake:

The fact that we have the second-worst infant mortality rate in the developed world is a statistic that I think people need to know about.
Ina May Gaskin:
We have the highest maternal health care costs, yet our infant mortality rate is high ...
Jennifer Block:
...the United States has the most intense and widespread medical management of birth" in the world, and yet "ranks near the bottom among industrialized countries in ... infant mortality.
These statements imply that infant mortality is a measure of obstetric care, but it is not. It is a measure of pediatric care and therefore, it is the WRONG statistic to use when discussing maternity care.

According to the World Health Organization, the best measure of obstetric care is perinatal mortality, usually defined as deaths from 28 weeks of pregnancy (stillbirths) through 28 days of life. And according to the World Health Organization, the United States has one of the lowest perinatal mortality rates in the world, lower than Denmark, the UK and the Netherlands.

Professional homebirth advocates don't want their followers to know the truth, so they deliberately use the wrong statistic to create a false and misleading impression of American obstetric care.

A graphical view of the various measurements of mortality that are commonly used in pregnancy and early childhood shows exactly how professional homebirth advocates misuse statistics.





This illustration shows the last few months of pregnancy and the entire first year of a baby's life. The first thing to notice is the tremendous difference between perinatal mortality (bounded by the purple bracket) and infant mortality (bounded by the green bracket). Indeed, there is barely any overlap, demonstrating that perinatal mortality and infant mortality measure very different things.

The only thing common to both measures is death from birth to 28 days of life. That is known as neonatal mortality. It captures nearly all deaths in the aftermath of childbirth, but, and this is critically important no deaths during childbirth. Deaths during childbirth, which by any possible account is a critical reflection of obstetric care are recorded as stillbirths.

So infant mortality is missing deaths during childbirth. In addition to leaving out this major component, it adds a tremendous amount of extraneous data in the form of deaths from 1 month of age to 1 year of age. These include deaths from Sudden Infant Death Syndrome (SIDS), childhood diseases and accidents, all irrelevant to the issue of obstetric care. That's why infant mortality is an excellent measure of pediatric care, but a very poor measure of obstetric care.

So infant mortality and perinatal mortality aren't remotely interchangeable and it is deliberately deceptive to use infant mortality as a measure of obstetric care.

What about neonatal mortality (bounded by the blue bracket)? Is that a good measure of obstetric care?

It is definitely better than infant mortality because it doesn't include tremendous amounts of extraneous information, and it is a useful proxy in countries that don't collect data on perinatal deaths. However, it leaves out a lot of very important information.

Neonatal mortality also does not include deaths during childbirth, arguably a very important measure of obstetric care. In addition, it leaves out late stillbirths. Late stillbirths are also an important measure of obstetric care since most of the interventions associated with late pregnancy and childbirth are designed specifically to prevent stillbirths.

In addition, and this is an exceedingly important caveat, many countries, such as the Netherlands, have attempted to make their neonatal mortality statistics look better by deliberately and deceptively classifying very premature live babies as stillbirths even though they are not dead. That way, very premature babies are automatically removed from both the neonatal and the infant mortality statistics.

This deception allows countries like the Netherlands to have infant mortality rates that are automatically and artificially lower than the real neonatal mortality rates. That's yet another reason why a direct comparison of infant mortality rates between countries like the Netherlands and the US (which classifies all liveborn babies as alive, regardless of prematurity) are deceptive.

Even the briefest glance at the illustration above makes it exceedingly clear that perinatal mortality and infant mortality are two very different measurements and are not in any way interchangeable. The fact that professional homebirth advocates like Ricki Lake, Ina May Gaskin and Jennifer Block imply that they are interchangeable tells us something very important about homebirth advocacy.

First, professional homebirth advocates do not hesitate to employ deliberate deception in order to impugn modern obstetrics. Second, professional homebirth advocates rely on the fact that their followers lack the most basic knowledge of statistics and therefore will not notice the deception. Finally, professional homebirth advocates demonstrate utter contempt for the truth.

The truth is that American obstetrics provides high quality care as reflected in the fact that American perinatal mortality rates are among the lowest in the world. But the truth doesn't sell homebirth videos, books and courses, so the truth must be hidden and misleading claims must be substituted.

Homebirth advocates and women contemplating homebirth need to ask themselves a very important question: If professional homebirth advocates have such utter contempt for the truth that they deliberately use the wrong statistics, how can you believe anything they write or say?


This piece first appeared on The Skeptical OB in September 2011.

Infant mortality is the wrong statistic



Professional homebirth advocates routinely trick their followers by preying on their gullibility and lack of basic knowledge of science, statistics and obstetrics.

Consider the following statements:

Ricki Lake:

The fact that we have the second-worst infant mortality rate in the developed world is a statistic that I think people need to know about.
Ina May Gaskin:
We have the highest maternal health care costs, yet our infant mortality rate is high ...
Jennifer Block:
...the United States has the most intense and widespread medical management of birth" in the world, and yet "ranks near the bottom among industrialized countries in ... infant mortality.
These statements imply that infant mortality is a measure of obstetric care, but it is not. It is a measure of pediatric care and therefore, it is the WRONG statistic to use when discussing maternity care.

According to the World Health Organization, the best measure of obstetric care is perinatal mortality, usually defined as deaths from 28 weeks of pregnancy (stillbirths) through 28 days of life. And according to the World Health Organization, the United States has one of the lowest perinatal mortality rates in the world, lower than Denmark, the UK and the Netherlands.

Professional homebirth advocates don't want their followers to know the truth, so they deliberately use the wrong statistic to create a false and misleading impression of American obstetric care.

A graphical view of the various measurements of mortality that are commonly used in pregnancy and early childhood shows exactly how professional homebirth advocates misuse statistics.





This illustration shows the last few months of pregnancy and the entire first year of a baby's life. The first thing to notice is the tremendous difference between perinatal mortality (bounded by the purple bracket) and infant mortality (bounded by the green bracket). Indeed, there is barely any overlap, demonstrating that perinatal mortality and infant mortality measure very different things.

The only thing common to both measures is death from birth to 28 days of life. That is known as neonatal mortality. It captures nearly all deaths in the aftermath of childbirth, but, and this is critically important no deaths during childbirth. Deaths during childbirth, which by any possible account is a critical reflection of obstetric care are recorded as stillbirths.

So infant mortality is missing deaths during childbirth. In addition to leaving out this major component, it adds a tremendous amount of extraneous data in the form of deaths from 1 month of age to 1 year of age. These include deaths from Sudden Infant Death Syndrome (SIDS), childhood diseases and accidents, all irrelevant to the issue of obstetric care. That's why infant mortality is an excellent measure of pediatric care, but a very poor measure of obstetric care.

So infant mortality and perinatal mortality aren't remotely interchangeable and it is deliberately deceptive to use infant mortality as a measure of obstetric care.

What about neonatal mortality (bounded by the blue bracket)? Is that a good measure of obstetric care?

It is definitely better than infant mortality because it doesn't include tremendous amounts of extraneous information, and it is a useful proxy in countries that don't collect data on perinatal deaths. However, it leaves out a lot of very important information.

Neonatal mortality also does not include deaths during childbirth, arguably a very important measure of obstetric care. In addition, it leaves out late stillbirths. Late stillbirths are also an important measure of obstetric care since most of the interventions associated with late pregnancy and childbirth are designed specifically to prevent stillbirths.

In addition, and this is an exceedingly important caveat, many countries, such as the Netherlands, have attempted to make their neonatal mortality statistics look better by deliberately and deceptively classifying very premature live babies as stillbirths even though they are not dead. That way, very premature babies are automatically removed from both the neonatal and the infant mortality statistics.

This deception allows countries like the Netherlands to have infant mortality rates that are automatically and artificially lower than the real neonatal mortality rates. That's yet another reason why a direct comparison of infant mortality rates between countries like the Netherlands and the US (which classifies all liveborn babies as alive, regardless of prematurity) are deceptive.

Even the briefest glance at the illustration above makes it exceedingly clear that perinatal mortality and infant mortality are two very different measurements and are not in any way interchangeable. The fact that professional homebirth advocates like Ricki Lake, Ina May Gaskin and Jennifer Block imply that they are interchangeable tells us something very important about homebirth advocacy.

First, professional homebirth advocates do not hesitate to employ deliberate deception in order to impugn modern obstetrics. Second, professional homebirth advocates rely on the fact that their followers lack the most basic knowledge of statistics and therefore will not notice the deception. Finally, professional homebirth advocates demonstrate utter contempt for the truth.

The truth is that American obstetrics provides high quality care as reflected in the fact that American perinatal mortality rates are among the lowest in the world. But the truth doesn't sell homebirth videos, books and courses, so the truth must be hidden and misleading claims must be substituted.

Homebirth advocates and women contemplating homebirth need to ask themselves a very important question: If professional homebirth advocates have such utter contempt for the truth that they deliberately use the wrong statistics, how can you believe anything they write or say?


This piece first appeared on The Skeptical OB in August 2011.