1. Homebirth increases the risk of neonatal death. This is accepted and acknowledged by the WHO, the CDC, NICE (The National Insitute for Health and Clinical Excellence), a healthcare watchdog in the UK, among other major health organizations. 

2. American direct entry midwives have less education and training than any midwives in the industrialized world. 

Henci, do you have more information about this? Thanks!

maria.

Both statements are gross falsehoods. Here is a quote from Care in Normal Birth: A Practical Guide, which is published by the WHO:

So where then should a woman give birth? It is safe to say that a woman should give birth in a place she feels is safe, and at the most peripheral level at which appropriate care is feasible and safe (FIGO 1992 [FIGO is the international Ob/Gyns professional organization]). For a low-risk pregnant woman this can be at home, at a small maternity clinic or birth centre in town . . . (p. 12)

World Health Organization. Care in Normal Birth: A Practical Guide. Geneva: World Health Organization; 1996.

And here is a quote from Sheila Kitzinger, writing in this year's March issue of Birth:

In September 2007 the UK National Institute for Health and Clinical Excellence (NICE) issued clinical guidelines on intrapartum care of healthy women and their babies during childbirth. Under "key priorities" it stated: "Women should be offered the choice of planning birth at home, in a midwife-led unit or in an obstetric unit." Information suggests that for "women who plan to give birth at home or in a midwife-led unit there is a higher likelihood of a normal birth, with less intervention" (p. 77).

Kitzinger K. Letter from Europe: home birth reborn. Birth 2008;35(1):77-8.

As for the canard that U.S. direct-entry midwives are poorly trained, a perusal of the North American Registry of Midwives (NARM) website gives the lie to that.

-- Henci  

Thanks, Henci I figured as much, but unlike you, I do not have the info in y head nor at my disposal that quickly.
 

maria.

Actually, both claims are both true.

Goer's quote from the WHO is out of date. The WHO said in April 2006:

Home-like settings for childbirth are associated with reduced likelihood of medical intervention. The evidence shows that the number of spontaneous vaginal births is higher, breastfeeding initiation more common and maternal satisfaction better in home-like institutional birth settings compared to conventional institutional settings. However, the evidence shows an increased risk of perinatal mortality, the reasons of which are not fully established. Thus, there is an increased need for monitoring early signs of complications in these home-like settings. (my emphasis)

As far as the NICE report is concerned, Goer didn't even answer the question. She was asked if NICE reports a higher rate of neonatal mortality at homebirth, and they do. From the same report that Goer quoted:

... intrapartum-related perinatal mortality (IPPM) for booked home births, regardless of their eventual place of birth, is the same as, or higher than for birth booked in obstetric units.
* If IPPM is higher, this is likely to be in the group of women in whom intrapartum complications develop and who require transfer into the obstetric unit...
* When unanticipated obstetric complications arise, either in the mother or baby, during labour at home, the outcome of serious complications is likely to be less favourable than when the same complications arise in an obstetric unit.

Goer tried to sidestep the direct question that she was asked about DEM qualifications. American DEMs have less education and training than ANY midwives in the industrialized world. There's no denying it and she didn't deny it.

Oh, ok. It seems I'll have to look into it more myself. Thanks for the info anyways.

 

The link you inserted for the WHO quote did not work, but I tracked down the quote by searching on the terms "World Health Organization" "April 2006" and "home-like." Those who know you will not be surprised to hear that you misinterpreted the WHO statement, which is about "home-like settings" in hospitals not home births. The WHO sources its statement to

 

Hodnett ED et al. Home-like versus conventional institutional settings for birth. The Cochrane Database of Systematic Reviews, 2005, 1, article number CD000012.

 

Without a source for the NICE statement, I will not venture to comment on what you are likely to have taken out of context or misrepresented except to say that it hardly seems likely that U.K. health care policy would promote home birth if it posed excessive risk, which, of course, it doesn't. 

 

Finally, the blanket accusation that U.S. direct-entry midwives have less training than other midwives in industrialized countries requires no denial because it is fatuous. The person who made it offered no comparison data to substantiate the claim. In fact, it would have been impossible to do so.  Midwifery training varies from country to country as does scope of practice. In many countries, midwives do not function independently but under the supervision of obs who set policies and make medical decisions. In some countries, they function the way intrapartum nurses do here and don't even catch babies. The training needed for practice in these situations is different than that needed by a midwife working independently who takes full responsibility for her clients. What is more, other than in the Netherlands, midwives are almost always trained to conduct hospital births exclusively, which is a whole different animal from home birth. To sum up, there is nothing to "deny" because the accusation has no substance. The real question is, "Do certified U.S. direct-entry midwives receive adequate training to properly care for women intending home births and their infants in the antepartum, intrapartum, and postpartum periods?" To answer it, one has only to show that the NARM certification process for midwives is rigorous and thorough and that to achieve certification, a midwife must demonstrate that she has the requisite knowledge, skill, and experience to care for women appropriately at out-of-hospital births. End of story.

 

-- Henci      

 

Thanks, Henci, that clarifies a whole lot for me as it fits with other things I have read as well.

Sorry to bring Dr. Amy here... this was a quote from her in a discussion online and I was wondering about it. The discussion is mostly a pissing contest between her and one other person, but I nonetheless want to look at everything Dr. Amy says for my own education.

maria.

Those claims were mine. Maria quoted them without attributing them to me.

Ms. Goer, you did not manage to rebut either claim, both of which are quite simple:

1. The CDC says homebirth increases the risk of neonatal death

2. US DEMs (including CPMs) have less education and less training than ANY midwives in the industrialized world.

Marsden Wagner himself acknowledges that the CDC strongly disagreed with him on his personal opinion that homebirth is safe. He writes about it proudly in his chapter, Confessions of a Dissident, in the book Childbirth and Authoratative Knowledge by Brigitte Jordan.

Moreover, you did not even address the latest CDC statistics from the linked Linked Birth/Infant Death 2003-2004 dataset. The data show that homebirth with a direct entry midwife has double to triple the neonatal death rate as hospital birth for low risk women.

And as long as we are discussing this issue, I will mention two additional points that you have never addressed:

1. MANA (the Midwives Alliance of North America) has been collecting safety data on homebirth since 2001. They have publicly offered the data to those who can prove they will use it for the "advancement" of midwifery. Even those people must sign a legal non-disclosure agreement preventing them from revealing any data to anyone. In contrast, the US and state governments make all birth data available each year on the internet. MANA's data almost certainly show that homebirth with a CPM has a much higher neonatal death rate.

2. Over a year ago, we argued about whether Johnson and Daviss used the correct comparison group in the BMJ 2005 study. I said that the correct comparison group was low risk hospital births in 2000. With that comparison (which Johnson and Daviss left out of the paper), they had ACTUALLY showed that homebirth with a CPM had a neonatal death almost triple that of hospital birth. You gave all sorts of excuses as to why they didn't need to use that group. Johnson and Daviss have since publicly acknowledged on their onw website that I am correct. You have not acknowledged it, and instead (as far as I can tell) deleted the posts you wrote in support of the wrong control group.

3. Maria pointed out to you in another post that the World Health Organization 2006 report on perinatal mortality (which shows that the US has a lower rate of perinatal mortality than Denmark, the UK and the Netherlands) and that this cannot be reconciled with your public claims that the US has a higher rate of perinatal mortality than other first world countries. Fortunately, you now acknowlede that the US perinatal mortality rate is comparable to other developed countries.

Finally, I would appreciate it if you would stop insinuating that I am not who I say I am,  that I do not have the credentials I list in my CV (Harvard '79; BU School of Medicine '84; Boston's Beth Israel Hospital internship, residency, staff appointment OB-GYN, Brigham and Women's Hospital staff appointment, Harvard Medical School Instructor in Clinical Obstetrics and Gynecology) or that I am in the employ of ANY organization. A public apology for your completely baseless, fabricated accusations would be appropriate.  If you promote such obvious and easily checked falsehoods about me, people might begin to think you are using the same tactic to promote homebirth.

In case you refuse to post or to delete this entry, readers can find it on my website.

Henci - you acknowledge that mid-wives have different training in each country. Are you familiar with the different requirements? Can you please detail what the differences are between American DEMs, CNMs and those certified/licensed in other industrialized nations? Also, I did note that you accused Dr. Amy of misinterpreting the WHO statement but clearly she included the "home-like setting" in her post and was transparent in including this in her post. Can you please explain to me how/why you believe she was misinterpreting the statement? The terms they use (as was included in her post) "home-like setting" clearly includes home births and birthing centers with a home-like setting as opposed to a hospital, correct? Do you believe that home-birth data as opposed to "home-like setting" would fare better if they were not lumped together? Do you have any statistics or data to support this?

This conversation baffles me. Neither the WHO or the NICE has recommended against planned home births. The World Health Organization citation provided above discusses improving antenatal care. It does not discuss home births at all. It does refer to a Cochrane database article about home-like institutional birth settings (such as in-hospital birthing rooms or birth centers attached to hospitals). The Cochrane database article that actually discusses home births concludes that there is no evidence that hospital birth is safer than planned home birth. Here are the links to the Cochrane database articles. Cochrane database: Home birth compared to hospital birth http://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD000352/frame.html Cochrane database: Home-like versus conventional institutional settings for birth http://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD000012/frame.html Here is some links to the NICE (National Institute for Health and Clinical Excellence) Full clinical guidelines: http://www.nice.org.uk/nicemedia/pdf/CG55FullGuideline.pdf guidelines for patients: http://www.nice.org.uk/nicemedia/pdf/CG55FullGuideline.pdf NICE does not say that home births are dangerous. It does caution awareness that “if something goes seriously wrong during your labour (which is rare) it could be worse for you or your baby than if you were already in hospital with access to specialised care.” On the flip side if a labor and birth are normal, being in a hospital carries increased risk of interventions and subsequent complications of the interventions. So a mother planning a home birth is still stuck with the original dilemma, predicting whether she is going to have an uneventful birth (likely) or a complicated one (rare but possible). In addition to the immediate causes of neonatal and maternal morbidity and mortality, delayed causes of death and injury to mother and infant such as suicide, substance abuse, or homicide are often not discussed. As a facilitator of a postpartum group, I believe that these problems can be traced in part to the mother’s birth experience and how that experience affects her perception of her mothering capabilities. In effect, the future life and death of each infant may depend on the empowerment of the infant’s mother through her birth experience. As a physician myself, I am offended by Amy Tuteur’s paternalistic attitude. Flaunting the M.D. to bully readers into trusting to your words demonstrates desperation and a certain mean-heartedness that sullies the title for other physicians. Since most obstetricians lack any training in home births and have most likely never even seen a in home birth, the title of MD carries very little substance. It makes much more sense to discuss the risks and benefits of home birth with a birth attendant who has seen the ins and outs of such a practice. Today's patients, like any other consumer, demand transparency in their care and respect for their autonomy. We wish to make our own decisions about the type of care we receive including birth attendant and place of birth. ACOG also supports this approach, at least in theory if not in practice. See their excellent statement on the ethics of maternal care. http://www.acog.org/from_home/publications/ethics/co321.pdf http://www.acog.org/from_home/publications/ethics/co390.pdf Physicians may argue that patients cannot possibly learn all there is to know without becoming a physician themselves. On the other hand, I know very little about how to rebuild a car engine, but I can go to Consumer Reports or the NHTSA and make a choice based on reliability or gas mileage. We should have auditing organizations independent of care providers and payors, similar to the FEC. In this election year, we should all look carefully at how our government can protect consumer choice and consumer responsibility for their health and the health of their families. I recommend the book by Regina Herzlinger (coincidentally also from Harvard =) titled “Who Killed Health Care?” Tienchin HBAC mother and retired MD, FACS

Neither the WHO or the NICE say that "home birth has an increased rate of neonatal death compared to hospital birth for low risk women." I can find no statement from the World Health Organization that describes home birth as having an increased rate of neonatal death compared to hospital birth. The statement from NICE: "There is a lack of good-quality evidence relating to women’s and babies’ short- or long-term outcomes for birth at home compared with hospital and there is no evidence on serious maternal morbidity and mortality. Limited low-quality evidence shows less intervention with a planned home birth compared with a planned birth in hospital. Transfer rates between home and hospital settings show great variation. While only three low-quality studies reported IPPM or intrapartum perinatal mortality rates, the findings suggest that there may be a trend towards higher rates when birth was planned at home. The unreliability of these data means that these findings should be interpreted with caution. Factors leading to the unreliability of the data include: • a lack of routine collection of data on place of birth • the mix of high- and low-risk women in the home-birth studies • the majority of women in these studies were self-selected populations, which questions the generalisability of the studies • inconsistent definitions • questionable relevance to the UK setting." Is the MANA data not published in the BMJ? http://www.bmj.com/cgi/content/full/330/7505/1416 But this only confuses a mother trying to make a decision. Because data from studies like these are collected, analyzed, and published by providers who have financial and personal investment in the outcome, she always feels that someone is pushing their agenda. A source of information that is somewhat more objective might be Childbirth Connection. http://www.childbirthconnection.org/article.asp?ClickedLink=252&ck=10145&area=27 What would really be terrific is for independent organizations who answer directly to the consumer, the patient/ mother/ client to provide an analysis of the immense information out there about pregnancy and childbirth. These centers would have an incentive to provide accurate and thorough information to the consumer because that is how they would stay in business. One model of this type is the "Center for the Childbearing Year" proposed by Raymond DeVries. http://docserver.ingentaconnect.com/deliver/connect/lamaze/10581243/v16n4/s8.pdf?expires=1214781533&id=44888322&titleid=10348&accname=Guest+User&checksum=BEE114ED9A0F06724724E7D92BDC23A9 Tienchin

"In addition to the immediate causes of neonatal and maternal morbidity and mortality, delayed causes of death and injury to mother and infant such as suicide, substance abuse, or homicide are often not discussed. As a facilitator of a postpartum group, I believe that these problems can be traced in part to the mother’s birth experience and how that experience affects her perception of her mothering capabilities. In effect, the future life and death of each infant may depend on the empowerment of the infant’s mother through her birth experience."

Do you have any research to support this claim? I find it extremely hard to believe that suicide, substance abuse and homicide can be attributed solely to a mother's birth experience.

It is unfortunate that the data for 2001-2007 is not available. I look forward to its publication. The data for 2000 published in the BMJ does not show that “homebirth with a CPM to have almost triple the rate of neonatal mortality as low risk hospital birth in 2000.” The BMJ article takes 5418 women who intended to birth at home at the start of labor. Out of these “five deaths were intrapartum and six occurred during the neonatal period. This was a rate of 2.0 deaths per 1000 intended home births.” Babies who die during labor and before birth are counted in intrapartum mortality rates. Babies born alive that die in the first 28 days of life are counted in neonatal mortality rates. So their home birth neonatal mortality rate was 6/5418 = 1.1 per 1000 births and their combined intrapartum and neonatal mortality rates was 2.0 per 1000 intended home births. Ideally, the mortality rate of a cohort who had planned hospital births would be compared to this group of 5418 women. In addition, factors other than place of birth that could change the mortality rate such as practice patterns, prematurity, etc would be similar in both groups of births. The authors of the BMJ article present several different sources for such a cohort to compare to their combined intrapartum and neonatal mortality rate. The combined intrapartum and neonatal mortality rates for hospital births ranged from 0.5 to 3.4 per 1000 births. Unfortunately the CDC National Vital Statistics Report on Infant Mortality Statistics from the 2000 period does not provide numbers for a matched cohort of births. The fact is that all the existing scientific evidence to date shows clinically undetectable differences in neonatal mortality rates between planned home birth and hospital births. No good data demonstrates that neonatal mortality is lower in hospital births compared to home births. Fortunately, no matter where a birth is planned, neonatal mortality is low. Unfortunately, for most families, scientific outcome measures are difficult to translate into a decision regarding where to birth. They have no way to measure what the local obstetrician’s or midwife’s neonatal mortality rates are. They may be exactly the same as those seen in published studies or they may be different. Tienchin

Actually, the CDC does not provide the data. Link to the pdf file: http://www.cdc.gov/nchs/data/nvsr/nvsr50/nvsr50_12.pdf The Linked Birth/ Infant Death dataset for 2000 presents tables describing INFANT mortality data by a variety of maternal and infant characteristics. INFANT mortality rates include live born babies that died in the first year of life. Our discussion has been about NEONATAL mortality rates which include live born babies that died in the first 28 days of life. The BMJ article examines combined INTRAPARTUM AND NEONATAL mortality which includes babies that died during labor and live born babies that died in the first 28 days of life. The Linked Birth/ Infant Death dataset for 2000 has only one table, Table 6, with information regarding neonatal mortality rates. This table describes neonatal mortality rates based on race and gestational weight only. It does not subdivide neonatal mortality rates based location of birth, gestational age, or the presence/ absence of lethal birth defects. The CDC data presented in the Linked Birth/ Infant Death dataset for 2000 is not an appropriate cohort of births to compare to the MANA data published in the BMJ. Tienchin

 

My bad for not getting back to this Forum sooner. The last time you posted to this Forum, I set ground rules for you: you would have your opportunity to state your case and make one rebuttal to my response, and then we were done. I'm going to reinvoke that rule and delete all of your posts that appear after this one.

 

1. You have provided no source for the allegation that the CDC reports a higher perinatal death rate at home births. I have tried various search combinations, but I am unable to find your source. If you write back with the source so I can review it, I will not delete your post, and I will respond to it.

 

2. You have supplied no information about the training of DEMs or how it compares unfavorably with the training of other midwives--not that such a comparison would be useful or valid for the reasons I stated in my first response to you, namely, In what country? Under what circumstances? What are the specific defects of DEM training? Appropriate training would vary according to the midwife's scope of practice and the conditions under which she works. To repeat, the key issue is whether a midwife with NARM certification, that is, a "Certified Professional Midwife" or CPM, has the requisite knowledge, skill, and experience to properly care for women planning home birth. If you perceive flaws or weaknesses in the training, by all means list specific deficiencies, and, again, I will not delete your post, and I will ask a guest expert to respond. If not, then please cease to malign DEMs. I would also add that midwifery training to work in hospitals would not adequately prepare a midwife to work out of hospital.

 

3. I will not rehash the argument over the Johnson and Daviss study. My response is elsewhere on this Forum.

 

4. I have no problem correcting what I have said if someone presents facts that contradict it or a reasoned argument why I am wrong. You have never done either. In this case, I was lazy in that I was repeating what I have read and heard. I will add, though, that the singleton preterm birth rate and low birthweight rates are on the rise and that the overuse of cesarean surgery is playing a role in this.

 

5. I have nothing to apologize for. It is a fact that no one can find evidence that you currently hold a license to practice medicine. One correspondent who tried to get background information on you found that the holder of your domain name is hidden, something that, according to this same poster, costs more and is not usual practice. Your website appears as a "sponsored site" when searching on certain topics, which I would expect--although this is speculation--probably costs a pretty penny. If any of these statements are factually incorrect, let me know, and, as before, I will not delete your post. Meanwhile, putting these facts together, it is not unreasonable to speculate that you are backed by an organization, ACOG being the most likely candidate, although it escapes me why you would want me to apologize for that. I, for example, am pleased and proud to be an independent contractor with Lamaze International.

Finally, thanks for the free promotion. Two new posters to this Forum found out about it via your posts on your website.

-- Henci

 

Thanks, Henci. I will look at that study again. I just have got to get to the bottom of this one, lol. 

It is confusing and upsetting when people look at one and the same study and come with different conclusions. It is infuriating especially when some of those  people also have low esteem for the lay person. When someone is so blatant about that, it is hard to trust anything they say. How words are used and tone of posts becomes very important.

The truth is revealed, not just through the facts but also, when the facts are hard to see clearly, through the underlying respect or lack thereof in some cases.

Thanks for your information and patience!

maria.
 

Looking for something else to respond to a post on another thread, I hit the CDC's most recent report on perinatal mortality in 2003. If you know Tuteur, you will not be surprised to hear that it says nothing about care providers.

-- Henci

"I hit the CDC's most recent report on perinatal mortality in 2003. If you know Tuteur, you will not be surprised to hear that it says nothing about care providers."

Have you no shame?

You already deleted the link to the data, so that you could pretend it was never posted here. Now you arbitrarily pick a completely unrelated paper and claim the data is not in there. No surprise since it is a paper about something else entirely.

Really, Amy, your playground bullying tactics don't cut any ice with me. I spelled out the rules for this Forum. If you send a link to the CDC document you claim states that having a DEM increases risk of perinatal mortality, I will not delete your post, and I'll follow up on it.

-- Henci