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Wednesday
Aug112010

BMJ Deputy Editor on Home Birth: 'Throwing the baby back into the bathwater'

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By Jill—Unnecesarean

Deputy editor of the British Medical Journal, Tony Delamothe, published an article in the BMJ to answer the question “What explains the fall in planned home births in developed countries?

Here are two interesting excerpts:

 

On the rise of hospital birth as the alternative to home birth:

Since the second world war numbers of planned home births have fallen precipitously in the developed world, mostly to rates of less than 5% of all births. Yet over that time no compelling evidence has emerged that hospital delivery—the main alternative—routinely produces better outcomes in uncomplicated pregnancies. That has not stopped the issue becoming highly contentious, with official bodies lining up on opposite sides of the argument. For example, the United Kingdom’s Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives think that planned home births are fine. The American College of Obstetrics and Gynecology and the Australian Medical Association do not. 

 

On the Wax paper:

As they might do with the second study, published last month in the American Journal of Obstetrics and Gynecology (doi:10.1016/j.ajog.2010.04.041; see BMJ 2010;341:c3551, doi:10.1136/bmj.c3551). This meta-analysis of 12 studies from “developed Western countries” compared outcomes of 342 056 planned home and 207 551 planned hospital deliveries. As in the Australian study, perinatal mortality (this time defined as the sum of stillbirths among fetuses of at least 20 weeks’ gestation or 500 g weight and deaths of liveborns within 28 days of birth) did not differ statistically between the two groups. So can home birthers now breathe a sigh of relief? 

Not so fast. For reasons unclear from the published article the authors switched their attention to neonatal mortality (perinatal mortality minus stillbirths) (BMJ 2010;341;c4033, doi:10.1136/bmj.c4033), despite having relevant data for these calculations on only 9% of their total sample. Neonatal deaths were twice as high among the planned home birth group and three times as high among infants without congenital abnormalities. Despite the reassuring finding on perinatal mortality, it was these differences in neonatal mortality that were seized on by the headline writers of medical journals and newspapers alike. (None of them thought to ask why stillbirths suddenly didn’t matter.) 

 

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Reader Comments (6)

There is a whole slew of responses in the BMJ this month. Are they accessible full text, or do you have to wait a month?

August 11, 2010 | Unregistered CommenterAly

As a strong homebirth advocate (and as someone who has had one myself, and would plan another), I am concerned by the neonatal death statistics / results from this study.

I'm most definitely not a statistics expert or phd, but 9% of the sample is approximately 50k people, so not a small sample exactly. Seems to be significant enough to draw preliminary conclusions from.

However, there are so many questions. What were the neonatal deaths attributed to? Are neonatal deaths reported more for planned homebirths than for planned hospital births, due to bias against homebirths (since only 9% had accurate data on this, is the reporting skewed toward homebirth since there is a cultural bias against homebirth)? I mean, neonatal death can be attributed to delivery, or to something entirely different...but if you had a culturally abnormal delivery method I'm sure the focus is going to land there more than if you birthed in a hospital, whether it had anything to do w/the death or not. Is it possible that people with known abnomalities incompatible with life went ahead with their homebirth plans so as to have their baby die a comfortable death and not one hooked up to tubes? I can see someone making that decision...

The 3x higher w/o congential abnormalities seems to be concerning, and surprising to me, given that countries with high homebirth rates compared to us have much lower infant mortality (which would include neonatal).

Just wondering if anyone has any knowledge/thoughts.

August 12, 2010 | Unregistered CommenterAnne

So, wait, if there is no statistical difference in perinatal mortality, but a higher neonatal mortality, and neonatal=perinatal-stillbirth, then the stillbirth rate in hospital births must be higher, am I reading this right? Any ideas on what is going on here?

August 12, 2010 | Unregistered CommenterWhitney

<<So, wait, if there is no statistical difference in perinatal mortality, but a higher neonatal mortality, and neonatal=perinatal-stillbirth, then the stillbirth rate in hospital births must be higher, am I reading this right? Any ideas on what is going on here?>>

Maybe interventions done in a hospital (such as pit/epidural) that can stress the baby and slow labor contribute to this.

Take a baby who for whatever (apparently unknown) reason will die shortly after or during birth. If labor is slow, as often happens when an epidural is placed and women labor on their backs, then the baby may die in utero. Whereas in homebirths, where mom is allowed to move around, ***generally*** labors would be shorter (at least natural, non-pit labors) and the baby may get a few moments of life outside the womb before dying?

Also, hospitals tend to pit women after the epidural has slowed down labor...pit contractions are unnaturally strong and often stress the baby. Therefore, pitting a baby that's going to die either way might hasten the demise.

Just a few ideas of what could cause this discrepancy.

I still wonder though if there's not sever overreporting of neonatal deaths attributed to homebirths compared to hospital births, since only 9% of participants had this data. It's quite possible that the other 91%, neonatal deaths in hospitals are 4x higher. However, it's a cultural assumption that if you were in the hospital and the baby died anyway, you did everything you could do...in this case, they might not have felt the need to report what type of birth the mother had, since they "tried everything." Whereas, if you had a homebirth, you're irresponsible and care more about the experience than the baby, right? So if there is neonatal death, we need to highlight the homebirth, because it fits with our cultural (unsubstantiated) stereotype.

I also wonder even if the stat is accurate, what countries were studied. Because if the countries favor homebirth, this might be a significant finding. But if the countries are like the USA and actively discourage it, then women and midwives may hesitate to transfer when necessary just a few minutes more, as they know they'll be treated like pariahs. Those few minutes may mean the difference between life and death. So...even if true....maybe it's not that homebirth is to blame, but the adverse homebirth climate. I just wonder if anyone has info on this part of the study as well.

August 12, 2010 | Unregistered CommenterAnne

My understanding is that the studies that provided the statistics that led to the "triple neonatal death" headline were flawed in that they did not distinguish between planned and unplanned home births (for example, the Washington state study, which has been previously discredited and which relied upon birth certificate data). Also the 1982 Western Australia study was included, which is both outdated and methodologically suspect, as I understand it. There is a HUGE difference between planned and unplanned home births in terms of outcomes, and it also makes a big difference whether or not a skilled attendant is present. The more informative numbers come from the Dutch study that provided the bulk of the births in the metaanalysis, as well as from the 2005 North American study that the Wax paper -- surprise, surprise -- did not include in the metaanalysis.

In other words, I don't think there is anything at all to be alarmed about, because all the methodologically sound evidence indicates that planned homebirth with a skilled attendant is as safe as hospital birth for low-risk women. This analysis was done to create a bad headline, and it succeeded in doing so. But when you look beneath the surface, there is no "there" there.

August 12, 2010 | Unregistered CommenterStar

http://www.theglobeandmail.com/life/health/us-analysis-on-home-birth-risks-seen-as-deeply-flawed/article1624918/

Here's a commentary on the study from Canada.

The comments to the article are grossly uninformed however...and insist that the Canadians are just anti-American, mothers that choose homebirth are morons and should be charged with manslaughter if the baby dies, and laud Dr Amy Tuter. All above-board pure scientific arguments, no emotion or strawmen there....

August 12, 2010 | Unregistered CommenterAnne
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