So, medically speaking, giving birth at home has some advantages. Women are less likely to get infections when they give birth at home rather than in a hospital. Babies born at home are more likely to be healthy (assuming it’s a low-risk pregnancy), and there is less medical intervention. The latter isn’t necessarily an upside, but it is what some women want.
However, according to a new study, home births have one very big drawback: Babies born at home are more likely to die. In fact, infant mortality rates for home births are two or even three times as high as those for hospital births. We’re still talking about a tiny percentage of babies who die (less that 1 percent in both home and hospital births), but that fact is hardly comforting if the baby is yours.
The medical journal The Lancet jumped on board with an editorial titled “Home birth—proceed with caution” that included this guaranteed-to-provoke line: “Women have the right to choose how and where to give birth, but they do not have the right to put their baby at risk.” OK, but when there’s real disagreement about the degree of risk, who has the “right” to make the decision?
Naturally, the report has been criticized by pro-home birthers. They say that the American Journal of Obstetrics and Gynecology, which published the report, is just toeing the official line, that some of the studies cited in the report are out of date, etc.
There are a couple of factors that make studying the safety of home births tricky. One is that you can’t have a randomized trial: Women usually have strong opinions about where they choose to have their babies and are unlikely to allow researchers to dictate that decision for the sake of science.
Also, not all home births are created equal. Fewer than a third of women have a certified midwife on hand for the delivery. Others have a midwife who may or may not be properly trained. And a few don’t have midwives at all. In addition, some midwives are “integrated into the health-care system,” i.e., they have ready access to a hospital should something go wrong. Within the category “planned home birth” there are a lot of variables.
The authors of the AJOG study conclude:
Future research needs to be directed at identifying contributors to and reducing the apparently excessive neonatal mortality among planned home births.
Hard to disagree with that. Though maybe some research also needs to be directed at figuring out why babies and their mothers tend to be healthier when births take place at home.
(Here’s the abstract for the study, “Maternal and newborn outcomes in planned home birth vs planned hospital births: a metaanalysis.” The authors are Joseph R. Wax, M.D.; F. Lee Lucas, Ph.D.; Maryanne Lamont, M.L.S.; Michael G. Pinette, M.D.; Angelina Cartin; Jacquelyn Blackstone, D.O.)
10 Responses to The Other Birther Controversy
astewart1 - August 6, 2010 at 12:04 pm
Home births today are a moot point in many states, including Nebraska, where I tried to have my second child nearly two decades ago. Certified nurse midwives? If you want to have safe home births it is important to have a system of certified nurse midwives with hospital back-up in place, and that is certainly not the case in many states at the moment. But why is this article in the Chronicle?
11333651 - August 6, 2010 at 12:28 pm
The conflict between autonomy — in this case, the mother’s right to make a choice — and beneficence — here, the obligation to protect the unborn child — is a classic conflict in medical ethics. As such, tools used to resolve such conflicts will prove useful.The question posed at the end of the article above, “why babies and their mothers tend to be healthier when births take place at home” likely has at least a partial explanation in sample selection. Most mothers who give birth at home have consciously and thoughfully considered their options and have chosen home birth. Such conscientiousness likely extends to other aspects of their pregnancy, and so may be associated with more attention and care given to optimizing the pregnancy outcome. Of course, women who choose hospital delivery may also manifest the same prenatal care, but a comparison of home births vs. hospital births will also include in the latter group those women whose prenatal care (or lack thereof) is suboptimal.
22028881 - August 6, 2010 at 1:16 pm
There is a substantial amount of historical scholarship that has informed some of the modern-day studies (I’ve written on the transition from midwives to physicians “Catching Babies” (Harvard, 1995),and the scholarship by Judith Walzer Leavitt suggests that women moved to the hospital because they were afraid of dying in childbirth. With that fear removed, modern-day parturient women have felt they have more choices that they feel are “safe.” All that being said, the data for this study is problematic–ie nurse midwives, direct-entry midwives, and no attendant at all–mean that the study was looking at dramatically different types of births. Nurse-midwives must have medical backup, and many direct-entry midwives also practice with some “medical” backup, and will “transport” mothers and babies who are in trouble. Women having no attendant at all have no backup, and it could be expected would have substantial risks.
kcook08 - August 6, 2010 at 3:22 pm
HOME BIRTH REBUTTAL “The danger with home births is not have a baby at home, but rather other people’s attitudes,” according to Sheila Kitzinger, an author who birthed all five of her daughters at home in England where it’s accepted.From researching for over a decade and interviewing midwives, doctors, hospitals, birth centers and yes, home birth moms, what you are not getting from this report are those statistics that show hospital errors, deadly staph infection, women who are not followed-up at home from c-section surgery and experience complications, the absurdly high 1-in-3 c-section rate in the U.S. and more. All of this research and interviews are included in a book I wrote with Dr. Margaret Christensen, M.D., Birthing a Better Way: 12 Secrets for Natural Childbirth.If the “Percolater” of this article searched outside of the U.S. (which has an abysmal ranking of 41st maternal mortality in the world when we spend more than any other country on maternal care) one would find a Canadian article accusing ACOG of providing political ammunition, below: Planned home births are linked to a tripling of infant mortality compared with planned hospital births, according to a U.S. review that “drew sharp criticism from Canadian researchers whose data was used in the study.”Dr. Michael Klein, an emeritus professor of family practice and pediatrics at the University of British Columbia, said the U.S. conclusions are “crap” that don’t consider the facts.Data, methods questioned”It’s a politically motivated study that was motivated by the American College of Obstetrics and Gynecology who is unalterably opposed to home birth, and they probably were quite happy to publish this article because it fits with their political position,” Klein said.UBC epidemiologist Patricia Janssen, who collaborated with Klein, said the American study mixes their work with research dating back to the 1970s, and surveys with as few as five recorded births.”The data and the methods taints the quality of the study,” Janssen said, noting the review includes studies where the qualifications of the caregiver were not known.*____Birth is not a disease for healthy women and the time has come that you can find plenty of YouTube videos to prove it. We are at the threshold of a tipping point where there needs to be a bridge between hospital care for high risk and acceptance of healthy natural childbirth. Women like Jessica Alba, Cindy Crawford, Gisele Bundchen and more are opting for natural birth at home. With nearly half of all Ob/gyn medical students are female, a high percentage of these students stated they would be interested in seeing an out-of-hospital birth in a regional AMA survey.There are enough births to go around. It’s time for physicians to police themselves to the highest standards versus Amensty International causing human rights uproar about high c-sections. Women seek a holistic model of mind-body-spirit and if it’s not being met in hospitals, these consumers will seek it elsewhere. They live with their bodies, their babies and it’s their decision. Hospital LDR wards could improve their care with listening to their staff’s feedback and taking a cue from the hospitality industry. Critiquing home births, midwives and even those physicians who keep an open mind is like Custer’s last stand on the hill of the lucrative birth machine. But keep in mind even the critiques wouldn’t be here if it wasn’t for their great grandmothers birthing at home. Kalena Cook & Margaret Christensen, M.D.http://www.BirthingaBetterWay.com* Read more: http://www.cbc.ca/health/story/2010/07/02/home-births-safety.html#ixzz0vq3behAe
tombartlett - August 6, 2010 at 9:10 pm
Hello from the author of this post@astewart1 Because it’s about new research, which is the focus of this column/blog/whatever@11333651 Sure, there is definitely some self-selection going on. But I don’t think that explains why women who have home births have a lower rate of infection. @22028881 Exactly.@kcook08 I’m familiar with Michael Klein’s objection. But did you read the Wax study? Unfortunately, I can’t link to the whole thing because it’s gated, but calling it “crap” and saying that some of the studies in this meta-analysis are old doesn’t change what they found. I’ve read the same objections from home birth proponents on various websites but I have yet to read a point-by-point rebuttal of this study anywhere. Is it “politically motivated?” I don’t know. But if it’s accurate, I’m not sure that matters.
kcook08 - August 6, 2010 at 11:55 pm
What does matter?
tombartlett - August 7, 2010 at 10:25 am
@kcook08 Accuracy. The study says a higher percentage of babies born at home die. If that’s not true, I’d like to read a detailed explanation of how the Wax study’s methodology is flawed. I haven’t seen that. Maybe it’s out there and I haven’t come across it. The article you reference in your comment doesn’t provide much further information.As I understand it, the criticism of the study is two-fold:1) Some of the studies included in the meta-analysis are old.2) The qualifications of the caregivers attending the births varied widely.Both of those points are acknowledged in the Wax report. I’m not sure how that makes the results “crap.” Maybe the results are crap. I just want to hear how. Saying that home births are becoming more popular, or that Jessica Alba had her baby at home, is interesting but has nothing to do with infant mortality rates.
teachertools - August 10, 2010 at 1:19 pm
Last month, I was asked to investigate and respond to the Wax study for a non-profit group in my state. As a teacher of information literacy at the local college, I am passionate about good quality research. However, when faced with this study I was astonished that it had even made it to publication in a “science-based” journal.In addition to the two points you raise above, I would add what other baffled researchers have pointed out when examining this specific study: -Wax included high-risk mothers-Wax included babies born preterm (not fully developed)-Wax included babies unintentionally born at home-Wax further utilized data from birth certificates that are unreliable and inaccurate.-Wax didn’t include some major studies, such as the only high-quality (and fairly recent) home birth study done right here in the US (Johnson & Daviss BMJ 2005) which showed amazing outcomes for infants and mothers when attended by certified professional midwives.If the title of the study is “PLANNED home birth vs PLANNED hospital births” then all fatalities arising from UNplanned home births of high-risk women should have fallen under the statistics of “planned hospital birth.” After all, these births were not planned for or expected. Yet Wax included these abnormal and unplanned situations which, obviously, changed the percentage of deaths for out-of-hospital births instead of the percentage of planned hospital births. This is a glaring flaw at first glance.That said, when asking if the meta-analysis is “true,” the answer to that depends on what you actually want to know. If a mom with pre-eclampsia or placenta previa accidentally delivers a preterm baby, with no expert assistance, at home when she had planned to give birth in the hospital, you will most definitely see an increase in both infant and maternal deaths for those situations. Midwives will not agree to attend births of this nature (and these unusual “accidental” births are not included in legitimate studies of “planned” home birth). If a researcher is comparing numbers less than 1% to make extreme statistical statements such as “two or three times higher,” then they’d better make sure that all unqualified data is removed from the study. This data skews the results and is just one of the reasons that Wax’s statement has been criticized by far more than just the expected “pro-homebirth” crowd you’ve alluded to. One other thing worth mentioning is that THREE studies that were selected for this Wax meta-analysis (which covered 93% of the women included in the meta-analysis!), did not find ANY significant difference in perinatal outcomes between home birth and hospital birth.Another issue in information literacy is looking for biases. This includes other stakeholders, political motivation, and sources of study financing. The big question that has arisen over the last month is why this study, slated for a release date of September 1st, was fast tracked to an early online release of July 1st. This is highly unusual. Nevertheless, considering the huge US midwifery legislation that was ongoing through the month of July (such as Massachusetts and New York), this study would have proven quite valuable for rallying obstetrical groups ONLY if it was released prior to August 1st. So the original September 1st release wouldn’t have been helpful. It’s understandable why such controversy has arisen in such a short amount of time and why AJOG is being so harshly criticized for questionable financial biases and political motivation.We ALL want good, quality research to base our decisions on. I have my students do reverse searches to find other articles, press releases, and responses for articles, studies, or even website they want to use to defend their positions. In this case, there are so many press releases from professional organizations and expert responses to the Wax study. It’s worth taking a look around because they each bring up far more than we have time to address here in a comment section of a post on the Chronicle of Higher Education. I won’t list several dozen here, but another interesting one is found through the Coalition for Improving Maternity Services at: http://archive.constantcontact.com/fs078/1102083584231/archive/1103553258617.html
tombartlett - August 11, 2010 at 10:08 pm
@teachertools Thanks for this detailed and interesting comment. It seems to me that your key assertion is: “Wax included babies unintentionally born at home.” If that’s accurate, then that’s a big deal — because the paper emphasizes again and again that the comparison is between planned home births and planned hospital births. If unplanned home births are included, then that’s not apples to apples. Which of the studies that he cites includes unplanned home births? I’d very much like to know so I can go read it.
kcook08 - August 20, 2010 at 4:26 pm
There’s the next question: How do we know there are accurate statistics of babies who die in the hospital or as a result from overuse of interventions or contracting staph infection and then later dying at home?