Written on July 7, 2010 at 4:43 pm by Birth Sense
The headlines are popping up everywhere: Home birth triples risk of infant death! Home birth triples neonatal death risk! Home birth triples risks!
It’s enough to scare any sensible pregnant woman away from her home and into the hospital as soon as possible. But what perplexes me is that every commentary I’ve read on this study¹ has simply regurgitated the investigator’s conclusions, without actually looking at the study itself to determine if it is valid.
Since the study is not due to be published until September, I requested and received an advance copy of the article, to be printed in the American Journal of Obstetrics and Gynecology. As I read through the methodology and the studies that were included in the metaanalysis, I became increasingly surprised at the huge leaps the investigators took to draw their conclusions. They freely admit that planned home birth with a certified birth attendant did not have any greater risks than planned hospital birth. They admit that studies comparing midwifery care versus physician care within the hospital have indicated the superiority of midwifery care, with equivalent perinatal death rates, and low levels of interventions in the midwife group. How do they then leap to the conclusion that low levels of intervention = increased risk of neonatal death?
I decided to review every study that met the investigators’ inclusion criteria, and read the conclusion/finding of each study. The metaanalysis included 12 studies. One of those studies was too small to draw any conclusion, by admission of the investigators. One of the studies found a higher neonatal death rate in planned home births, but admitted that their findings may have been skewed by inclusion of unattended home births that were not planned. One study was done so long ago that the applicability of the findings to modern obstetric practices must be questioned.
That leaves nine studies, ALL of which concluded that planned home birth carries no higher risk of perinatal mortality than planned hospital birth, and less risk of morbidity (complications). I have listed below the 12 studies included, links to where you can view the abstracts and studies for yourselves, and each study conclusion in the investigators’ own words.
1. Koehler NU. Outcomes of a rural Sonoma county homebirth practice 1976-1982. My objection to inclusion of this study is that during the period of 1976 – 1982, the use of electronic fetal monitoring and ultrasound was in its early stages, and not used routinely in hospitals or home births. Since the conclusion of the metaanalysis was that fewer interventions are associated with an increase in neonatal death, a study from an era where neither birth site used the technology being touted as reducing neonatal mortality cannot be used to draw an accurate comparison.
2. Pang JWY. Outcome of planned home births in Washington State: 1989-1996. This study, included in the metaanalysis, has received wide criticism for its conclusion that planned home birth is riskier than planned hospital birth. The study authors themselves admitted, “This study has several limitations that are related to the reliance on birth certificate data. These include the potential for misclassifying unplanned home births as planned home births.” In Washington state, birth certificates indicate the place of birth, but not the intended place of birth, and the qualifications of non-physician birth attendants were not determined for this study. Thus the study may have included unintended home births, or home births without a certified birth attendant, and is not appropriate for inclusion in the metaanalysis.
3. Shearer JM. Five year prospective survey of risk of booking for a home birth in Essex. “The results of this study showed no evidence of an increased risk associated with home confinements but indicated that there were fewer problems than were encountered in the deliveries in mothers confined in hospital. ”
4. Woodcock HC. A matched cohort study of planned home and hospital births in Western Australia 1981 – 1987. “Planned home births in WA appear to be associated with less overall maternal and neonatal morbidity and less intervention than hospital births.”
5. Ackermann-Liebrich U. Home versus hospital deliveries: follow-up study of matched pairs for procedures and outcome. ”Conclusion: Healthy low risk women who wish to deliver at home have no increased risk either to themselves or to their babies. “
6. Wiegers TA. Outcome of planned home and planned hospital births in low risk pregnancies: prospective study in midwifery practices in the Netherlands. “Conclusions: The outcome of planned home births is at least as good as that of planned hospital births in women at low risk receiving midwifery care in the Netherlands.”
7. Lindren HE. Outcome of planned home births compared to hospital births in Sweden between 1992 and 2004. A population-based register study. “Conclusion. In Sweden, between 1992 and 2004, the intrapartum and neonatal mortality in planned home births was 2.2 per thousand. The proportion is higher compared to hospital births but no statistically significant difference was found. Women in the home birth group more often experienced a spontaneous birth without medical intervention and were less likely to sustain pelvic floor injuries.”
8. Janssen PA. Outcome of planned home births versus planned hospital births after regulation of midwifery in British Columbia. Conclusion: “There was no increased maternal or neonatal risk associated with planned home birth under the care of a regulated midwife. The rates of some adverse outcomes were too low for us to draw statistical comparisons, and ongoing evaluation of home birth is warranted.”
9. Dowsell T. Should there be a trial of home versus hospital delivery in the United Kingdom? This trial only included 10 women, 5 who gave birth at home and 5 who gave birth in the hospital. With numbers this small, it is impossible to draw any conclusion in regard to risks. Even the authors stated, “The trial was too small to draw any conclusions about home birth“.
10. de Jonge A. Perinatal mortality and morbidity in a nationwide cohort of 529 688 low-risk planned home and hospital birtdohs. BJOG 2009;116:1–8. “This study shows that planning a home birth does not increase the risks of perinatal mortality and severe perinatal morbidity among low-risk women, provided the maternity care system facilitates this choice through the availability of welltrained midwives and through a good transportation and referral system.”
11. Hutton EK. Outcomes associated with planned home and planned hospital births in low-risk women attended by midwives in Ontario, Canada, 2003-2006: a retrospective cohort study. Conclusion: “Midwives who were integrated into the health care system with good access to emergency services, consultation, and transfer of care provided care resulting in favorable outcomes for women planning both home or hospital births.”
12. Janssen PA. Outcomes of planned home birth with registered midwife versus planned hospital birth with midwife or physician. Conclusion: “Planned home birth attended by a registered midwife was associated with very low and comparable rates of perinatal death and reduced rates of obstetric interventions and other adverse perinatal outcomes compared with planned hospital birth attended by a midwife or physician.”
This is a situation where the evidence simply does not add up to the conclusion. The preponderance of the evidence still falls in support of safety of planned home births with a certified/registered/licensed attendant.
1. Wax JR, Lucas FL, Lamont M, et al. Maternal and newborn outcomes in planned home birth vs planned hospital births: a metaanalysis. Am J Obstet Gynecol 2010;203
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This is why I am delivering at the hospital in Portland, ME, that is *not* the one where the people who wrote the study work. . .
So what the hell, then?
Thanks for compiling all of these! It’s really shocking that despite obvious flaws, a study like this can still be published in a respected medical journal. Takes the right people with enough money…
Anyway, the worst part about this is most in the general public won’t ever see the actual studies. All they’ll remember is reading an article in the paper years ago that said home births are unsafe.
That is what concerns me the most as well. The fact that people will just remembering that they read somewhere that home births were unsafe. I don’t know how that can be combatted!
Thank you so much for this. I hate all the misinformation and scaremongering that comes with ANY discussion about homebirth,
Thanks for doing this excellent deconstruction. I will post it on the Big Push facebook page and website.
Foxy Katy, you ask “what the hell, then?” And Linnette asks why this journal would publish this deeply-flawed study? Well, as Dr. Klein suggested in his commentary on this article, the reasons for the timing and publicity behind the publication of the Wax Paper (good for little but wrapping a sandwich)are highly likely to be political. ACOG (which publishes its own journal), and the other OB groups (which publish this journal, AJOG) opposes home birth and has joined the AMA in calling for home birth to be made illegal in the U.S. ACOG is also involved RIGHT NOW in hard-fought legislative battles over licensure of midwives, including midwives who provide out-of-hospital birth services, in Massachusetts and New York State. ACOG can now try to use this article to play the long-discredited “dead baby” card AND “bad mother” cards with state representatives and governors. Such cynical tactics may surprise you, but the Big Push has found that organized medicine has no problem stooping to unfair tactics when trying to eliminate or control access to midwives.
And exactly the same thing is happening in Australia right now
hence Australia having the highest c/s rate in the world
I don’t get it. If there are counting these 12 studies, and the conclusions are as you have summarized, then where are they getting the “tripled risk” in their own conclusion? Is it that if you pool all the numbers, the non-significant numbers in each small study now add up to a number that is significant? Or something else?
They have pooled the numbers, including ones from the study that found higher death rates at home because it included ALL home births, planned or unplanned, accidental or otherwise. They admitted that when they compared only planned home births attended by certified providers, there was NO difference in death rates.
What was the rationale for not including Johnson and Daviss?
I had the same question. I have asked this question of the investigators, and if I get a response, I’ll let you know!
Johnson & Daviss did not compare their findings to a planned hospital cohort, which was one of the criteria for inclusion in the Wax paper: data for each study had to be “presentable in a 2×2 table”, meaning hospital versus home. If they had been pooling the neonatal mortality rates for all studies that looked at planned home birth, and compared that with NMRs for all studies that looked at planned hospital birth for low-risk women (independent of each other), Johnson & Daviss could have been included in that kind of analysis. But there are problems with that kind of analysis too.
What a helpful breakdown. So interesting that clearly among the studies used, the ones that had comparable outcomes for out of hospital and hospital birth also had midwives integrated into the health care system (BC, UK, Netherlands, etc.) The unfavorable stats in the first two studies came from places or scenarios that did not control for certified midwives. This metaanalysis is all about politics, not about research.
Actually, it’s the Pang study that is largely responsible for the findings of “triple” the neonatal mortality rate in the Wax analysis, and that is not because they didn’t control for type of midwife, but because they didn’t control for planned versus unplanned home births AND included preterm births (34 weeks and up) in their analysis. Roughly 40% of the data in Wax’s neonatal mortality analysis comes from the Pang study. It is widely known that unplanned homebirths have a much higher rate of complications and deaths, and it is also well established that preterm babies have a much higher rate of respiratory issues and deaths as well. It is not surprising that inclusion of the Pang study results in a tripling of the neonatal mortality rate, and that removing that study from the analysis results in no difference at all between home and hospital births. But Wax leaves that information in the fine print and chose instead to base his conclusions on the more sensationalistic (and flawed) finding of “triple the death rate!”
According to Pang, even after for controlling for gestational age, they had the same findings:
“We sought to minimize misclassification
of intended location of delivery in this study by
excluding infants born at less than 34 weeks’ gestation
and by excluding births in which complications were
identified during pregnancy. This source of misclassification
likely was further decreased when we restricted
the analysis to infants with birth weight of at least 2500 g
or to infants of at least 37 weeks’ gestation.”
I believe one reason that they still found higher risk of neonatal death after controlling for births before 37 weeks
is their admitted unintentional inclusion of accidental/unattended home births.
You rock.
It seems AJOG and all of their buddies who allowed this “study” (can you really call it that?) to not only take place but published early was to do what you mentioned in the first paragraph of this article. As you said, articles are flying up left and right called, “Home Birth Has Triple Death Rate,” or similar. Whether or not the study was accurate, they’ve done their job with that statement and the widespread conversation it has inspired. Now women (and their partners) can scan the internet searching for home birth information and see that article on AJOG. If for nothing else, no matter how flawed or politically motivated it is, they got their point out there. Scare women. Which is why we – advocates, home birth moms, midwives, doulas and the like, have to keep informing on the truth. Thanks for this article.
Thanks for breaking it down for the rest of us. It is difficult to fathom that sensible, intelligent OB/GYNs continue to buy into ACOG’s smoke and mirrors — everything from their practice guidelines to their position statements. I am grateful to writers like you, and all the other activists out there publicly denouncing this garbage. The Big Push folks, NACPM, MANA, Midwifery Today. Thank you all!
Could you post the “inclusion criteria” for the studies? I assume the authors wrote somewhere in the study why they chose what they chose, and why they excluded those that they did, since that seems to be pretty standard practice in meta-analyses I’ve read.
Also, starting in point 2 and going through point 6, the font gets tiny and is difficult to read; I hope you can fix that without too much trouble.
Yes, I’ll be happy to post this. I am out of town until Monday but will post it then.
I know for a fact that Wax’s Cousin had a perfect home birth in January with no interventions/drugs/ultrasounds or dopplers! But I don’t think he knows about it.
One has to wonder why a respectable organization like ACOG would publish what Canadian researchers are calling “crap” and British doctors are calling “politically motivated” information that can on better inspection seem to be flawed research. The reason is clear, and as Kaitlin Rose points out, they got their sensationalized headline out there to the American public. And, unfortunately, the American public generally won’t delve further for explanations, they will believe the headlines. We must come up with our own sensationalistic headline to get the truth out about this study. Any suggestions?
I guess respectable doesn’t necessarily mean scientifically responsible. ACOG has never been particularly stellar in their research. Consider how quickly the pendulum swung against allowing VBACs, all based on very little evidence and a letter to the editor of their journal.
I think your idea of a sensational headline is superb. . .the problem is, would the media promote it like they’ve promoted this metaanalysis? I have been amazed at the news reports I’ve read, simple regurgitating the study conclusion without actually reading it or doing any analysis of it.
This hits the nail on the head. Unfortunately, a scary story about someone dying will keep people on the channel or make them buy the magazine. Bonus points if the person dying is a pretty woman or a baby (especially in the USA). Even the shows based on real births try to drum up the drama – “So-and-so has had a perfect pregnancy and been laboring fine, but will she be able to deliver the baby?!” We don’t know! Come back after the commercial!
To fight headlines for this study it would have to be something equally gruesome as triple the death of babies. “Women are showing up at hospital only to have their stomach ripped open!” “Pregnant women are strapped to beds!” Unfortunately, advocates and researchers who promote home births are too sensible to take the low road and like headlines like “Mother gives birth to baby. Both are happy and healthy. Taking a nap on couch.”
How about:
“According to WHO, Two in Ten Women’s Uteri Unnecessarily Ruptured During Delivery”
or
“Doctors Counsel Uterine Rupture as Safe Alternative to VBAC”
or
“One Third of All U.S. Babies Extracted”
(Of course, I am equating c/sec w/uterine rupture here. But…IMO…a ercs is a 100% of uterine rupture, it’s just controlled. I’ll take 0.5%, or 0.3% since I’ve had a VBAC, to 100% any day.)
And, these statements are likely more true than the 3x statement ACOG made, based on what was presented above.
Fight fire w/fire?
I vote for something along the lines of “Triple risk of newborn death in hospital births’” turn it right back on them. Of course we’d need to get accurate numbers and studies to prove the increased risk of infant mortality during a hospital birth but that shouldn’t be hard to do.
YES!!
Thank you for taking the time to present this! I wish all new scare tactic studies and generalizing headlines had such a story to accompany them!
This article says it all:
http://midwiferytoday.com/articles/disinformation.asp
We are dealing with similar spin/misinformation as big lobby groups such as the tobacco and cigarette industries, this is not some bad reporting of a study, it is planned and the purpose is to continue to keep the public in the dark about the safety of home birth and normal birth. I think it’s time we started fighting back hard!
Hey, I take offence at the suggestion that I’m not sensible because I’m not scared away and plan to go through with my home birth!
Anyway, getting serious now… I really wish we could let people know that what they’re being told is wrong… but people unfortunately believe what they want to believe. My cousin told me off when I was pregnant with my first because I mentioned I’d like to try for a homebirth for my second, pushing me for an answer – “why would you do that when a hospital is safer?” – and no matter what I said, she either ignored me or told me I was wrong. Sigh.
Could somebody please give me the name of the lady who wrote the above article/blog? I’m quoting the information in an article I am doing for a South African parenting magazine, but need to know the writer’s name, location and qualifications. It appears she is an American midwife (so far so good) but I also need her name please, for the magazine to accept it. It can be emailed to me at kangacare@mweb.co.za
AMAZING!!! I can’t believe what people and organizations do and get away with, it is despicable. I’m sending this crucial analysis to the doctor in my family… and posting it everywhere possible. You all should do the same. People need to know the truth.
This much criticised study has now had its discredited findings repeated in The Lancet (once, a respected medical journal). That needs challenging too. Beverley
I don’t know where to ask this, but can someone tell me the number of planned home births that end up in the hospital somehow. Our insurance will not pay for a home birth. I really want one. It’s cheaper where I live and with our high deductible insurance, the hospital birth is about twice as much. But my husband is worried about high rates of having to go to the hospital anyway, even when the baby is okay. It would just make the birth more expensive overall than going to the hospital in the first place. I wish I didn’t have to worry about money.