Showing posts with label home birth safety. Show all posts
Showing posts with label home birth safety. Show all posts
Wednesday, September 3, 2014
Thursday, August 28, 2014
Home Birth in the USA
There are some things you may not know about home birth in the USA. For example, if you were told that "home birth is as safe as hospital birth" then you need to know that is, in fact, not true... not in America... not even for low risk women. Here is some information regarding midwives, birth centers, home birth, studies, statistics, guidelines, and more, that you may find useful for learning more about home birth in our country. There is a lot to read here but it is important information in order for you to make a fully informed decision.
Let's start with an introduction for those who have never stopped by before. My name is Dani. I'm a birth doula and former home birth advocate. Here's my story:
One key issue with home birth here is the many different types of midwives we have in the USA: CNMs, CMs, CPMs, LMs, LDMs, lay midwives..... So many!! Each type has different standards for education and training (or no standards at all). Here is an easy-to-read series that touches on the three main types of midwives:
Most home births in the USA are attended by a Certified Professional Midwife (CPM) or Licensed Midwife (LM) (CPMs and LMs are very similar). It's important to know that CPMs and LMs would not be able to be licensed in any other first world country. The standards simply are not rigorous enough. They are only legal in 26 states, do NOT earn hospital privileges as a part of their training process nor do they have any higher level education requirements -- as opposed to American CNMs/CMs and midwives in countries like the Netherlands, Canada and the UK. Safer Midwifery for Michigan has an eye-opening post that explains how little it potentially takes to earn the title “Certified Professional Midwife”:
Here is a great series exploring what it takes to become a midwife in other countries: The Education of Midwives Around the World
Many home birth midwives do not carry malpractice insurance. Why is insurance important? Insurance protects you. It means that if something happens that causes death or injury, you are able to have recourse and accountability. It means that if your child suffers an injury during birth, you can have compensation to help pay for life long care that may be needed.
There is no transparency for home birth midwives. They do not have a publicly accessible board where any disciplinary measures would be listed. How do you know if your midwife has ever practiced negligently, resulting in the death or injury of a baby or mother? What is your midwife's real record? How can you verify it? How do you know for certain how many births she has attended? Far too many mothers have trusted their midwives, trusted the friendship they developed with their midwives, trusted their judgement and reputation, only to find out after a bad outcome that their midwife was less than forthcoming.
* BIRTH CENTERS *
Is a freestanding birth center safer than a home birth? That depends. In many ways, a freestanding birth center birth is just a home birth in someone else's home. What equipment does your birth center offer that wouldn't be available at home? Is the distance to the hospital closer? What types of midwives are running the center and who will attend your birth? The 2013 Birth Center study shows that out-of-hospital birth can be a reasonably safe option. However, it's important to know that this study does NOT reflect all birth centers in the USA. It was a select group of birth centers, majority of which were run by CNMs. The birth centers met certain criteria and were CABC-accredited. Out of 248 freestanding birth centers in the USA, only 79 were included in the study. Read more about the Birth Center Study here:
* HOME BIRTH STUDIES AND STATISTICS *
Here are studies and statistics regarding home birth safety. It's important to look at studies done in the USA. Studies regarding home birth in other countries do not reflect home birth in America: different midwives, different health care systems. Outcomes will be better in countries where, for example, midwives have high standards for education and training and where the midwives have hospital privileges. These links are studies regarding home birth in America... and every single study shows a significant increase risk for babies born at home:
1. The 2014 MANA study, showing an increase risk of intrapartum and neonatal death of 3-5x for babies born to low risk women: Mortality rates from the new study by the Midwives Alliance of America
4. The latest study on home birth in the USA (Feb 2014): New Cornell study shows home birth has 4x higher death rate than comparable risk hospital birth
5. Risk of brain injury and home birth: Risk of anoxic brain injury is more than 18 times higher at home birth
* INFANT MORTALITY *
Advocates of the home birth movement use infant mortality to try to scare women away from our hospitals / maternity care.
Infant mortality is not the correct mortality rate to use to gauge safety of obstetrics / maternity care. Infant mortality is live birth through the entire first year. It does not include stillborn babies. It includes any and all deaths like accidents, disease, SIDS, etc that may happen day 4, day 204 or day 364... death at any time, for any reason for the first full year of life. Perinatal mortality is a much more accurate measure for maternity care (even the World Health Organization acknowledges this). It includes prematurity, fetal mortality (death of baby in utero), intrapartum mortality (death of baby during labor and delivery) and neonatal mortality (death of baby during first 27 days of life).
So why don’t the leaders of the home birth movement discuss perinatal mortality? Because the United States does very well with perinatal mortality, tied with countries like France and Japan, and actually better than countries like the Netherlands and the UK.
When will they stop trying to scare women using the wrong mortality rate?
* THE LIES AND MISINFORMATION *
Home birth in our country is sadly built on a foundation of lies and misinformation. An example is the press release written by MANA for the new MANA study: it's lies, cherry-picked info and misinformation. I shared more about this in an interview with SteadyHealth (as well as thoughts on HBAC/VBAC). To touch on this issue of the MANA study, I tried to put things into perspective:
"A home birth mortality rate of 1.62/1000 [from the new MANA study] for babies born to low risk women might not mean much of anything without having something to compare it to. 1.62/1000 just sounds low. However, when you compare it to the 2013 Birth Center study, for example, which has a mortality rate of 0.87/1000 for babies born to comparable risk women, then it makes you wonder why is the MANA study mortality rate twice as high?
These numbers all seem low, though. But it’s important to remember how many babies are born every year in the USA, specifically how many are born in an out-of-hospital setting. According to the CDC Wonder Database, in 2012 there were 38,997 midwife-attended out-of-hospital births - some in birth centers, some at home. So just for the sake of illustrating a point here, let’s round up to 40,000 births and let’s pretend they are all low risk women. According to the MANA study mortality rate of 1.62/1000, approximately 65 babies would die out of 40,000. According to the Birth Center study mortality rate of 0.87/1000, approximately 35 babies would die. According to the hospital mortality rate of 0.38-0.58/1000, approximately 15-23 babies would die. That’s a huge difference in the number of babies born at home that would not survive either childbirth or the first month of life. Now those mortality rates don’t seem so small.
What is home birth in America doing so wrong that their mortality rates are so much worse than hospitals and (certain) CABC-accredited birth centers? 1.62/1000 is the mortality rate for babies born to low risk women. This is not acceptable. Instead of addressing this issue and figuring out ways to make home birth better, safer they instead are spending their time trying to pull the wool over everyone’s eyes. They want people to think that 1.62/1000 is good. But it isn’t."
Read more here: SteadyHealth Interview
Another big source of misinformation is the popular film “The Business of Being Born.” Here is my critique of the film, which hits on misleading information that is widely shared, not just in this movie:
* GUIDELINES, EQUIPMENT & WHAT TO ASK YOUR MIDWIFE *
What makes home birth a reasonably safe option? Here are some guidelines:
What equipment is available at home versus in a hospital?
Home vs Hospital: The Equipment
Home vs Hospital: The Equipment
What questions should you ask your midwife?
Considering Out-of-Hospital Birth?
Considering Out-of-Hospital Birth?
Have questions or more suggested reading material? Share in the comments below or here on Facebook:
https://www.facebook.com/douladanielle/posts/646718472063552
Monday, January 13, 2014
Home Birth Safety
Link for above AJOG study
Edit 01/31/2013: I need to add the latest study offering up insight on home birth safety here in the USA. Click here to read it. It, yet again, shows increase risk for babies born at home.
I originally wrote this as a post in a forum online but I decided I wanted to share it here as well. This post addresses the peer reviewed studies regarding safety of home birth in our country.
It is important to know that studies done in other countries to "prove" the safety of
home birth do not apply to home birth
midwifery in the United States. Countries like the Netherlands, the UK,
Canada, etc have home birth midwifery
integrated into their health care systems. Their midwives have different
education and training... more similar to a CNM or CM here in the USA. CPMs and
LMs are a different story though, but they are the ones who attend majority of
home births in the USA. CPMs and LMs do not have hospital privileges. They
are not comparable to midwives in other first world countries in terms of
education and training, as most CPMs and LMs go through a direct-entry process
that has no education requirements (until September 2012 it did not even
require a high school diploma). There are other differences as well that I have
discussed in other blog posts (here and here).
For various other reasons, home birth in the United
States cannot be compared to home birth midwifery in other first world
countries. It's comparing apples to oranges.
Is home birth safe here in the USA? What we have for information to answer that question are 4 peer reviewed studies
plus the CDC Wonder Database, all of
which show an increase risk for babies born at home. Here are the 4
studies:
This study is the most well-known study in the home
birth community and the only study
that supposedly shows the proof that "home birth is just as safe as
hospital birth." But this study has two fatal flaws and it actually shows
the opposite, that home birth increases
the risk for babies.
First, the authors compared intervention rates
between home and hospital for the same year, 2000. But when they compared
mortality rates between home and hospital, they used the year 2000 for the home
birth rates BUT for hospital rates, they used several papers dating back to
1969. Why didn't they compare hospital rates for the same year? Because if they
would have, you find the rate to be double
to triple the risk. The authors claimed that they did not have the hospital
data available for the year 2000 when they published their study, which is why
they used the dated papers. You can read a critique here which shows the
numbers:
It is also important to note that crucial data is missing from this
study. In Autumn of 1999, NARM contacted all registered CPMs regarding
this study. Not everyone could be contacted, not everyone planned to
re-certify, not everyone agreed to participate. So they were left with 409 midwives.
All 409 midwives AGREED to take part in this study. Yet, 18 midwives ended up
not having their births used in the study - those 18 midwives were not able to
re-certify because participation was mandatory in order to do so.... however, this
does NOT mean those midwives are not still practicing. Where is the data on
those 18 midwives and their births? Why did they AGREE initially to take part?
What if they each had an infant or mother die under their care and that's why
they did not complete the process? This essentially means midwives who had bad
outcomes could bow out after the fact and those outcomes would then not be
included in the study.
These are two serious flaws. This is a study I once
was totally behind.... this is what I had my husband (and others) read when we
were planning for our home birth, this was my "proof" of home birth
safety. I was completely unaware of these flaws at that time. I even wrote a
response on the article in the British Medical Journal regarding the missing data on those 18 midwives but I have
yet to hear a response.
This study shows a triple neonatal mortality rate for babies born at home vs in a hospital but it isn't a high quality study because there are births included in the home birth group that did not have a midwife present (in other words, births that were intended to be hospital births that were accidental home births).
These last two are the most recent studies:
These two studies both show the risk to babies
is significantly higher for death, seizures or serious neurological
dysfunction for babies born at home and freestanding birth center. Home birth
and birth centers were compared to hospital births with OBs (which would
include high risk pregnant women) and hospital births with CNMs.
Hospital births with CNMs had the lowest rates (meaning, best outcomes -- which would make sense b/c it would be low risk women). Followed by hospital birth with a doctor. A fairly significant higher risk is midwife-attended birth center birth. The highest risk - by an incredibly significant amount - was home birth with a midwife.
Hospital births with CNMs had the lowest rates (meaning, best outcomes -- which would make sense b/c it would be low risk women). Followed by hospital birth with a doctor. A fairly significant higher risk is midwife-attended birth center birth. The highest risk - by an incredibly significant amount - was home birth with a midwife.
Some home birth advocates are trying to say these
studies are not valid because they use unplanned home births - this is NOT true. They used data ONLY from home and birth
center births where a midwife was present. If it was not midwife-attended
or if it was unknown whether or not there was an attendant, the data was not
used.
One of the limitations in the studies is actually
home birth transfers to hospitals that resulted in death... those would be
counted in the hospital group. This would obviously make the neonatal mortality
rate even higher for home births if those deaths were counted in the home birth
group.
Here is the response from MANA regarding these two
studies:
This response from MANA could not provide a better example of
why I have ZERO respect for that organization. It is full of lies
and utter nonsense.
First, they try to dismiss the findings by saying
birth certificates "are not very accurate when it comes to rare outcomes
like very low Apgar scores, seizures, or deaths (Northam & Knapp, 2006)."
In the comments, someone wrote that the study they
reference actually states the opposite, it states that APGAR scores are
actually quite accurate on birth certificates. So I read the study. And it
indeed does say that APGARs are reliable on birth certificates. Each time APGAR scores are mentioned in the study, it mentions that APGAR scores are one of the more reliable pieces of information on birth certificates. To quote the very study they reference exactly it says “Birthweight, Apgar score, and delivery
method agreed 91.9% to 100%. The high-percent agreement supports the
reliability of those variables.” So not only did they offer up completely
false information, but then when someone pointed it out to them, they did
nothing to edit or change it.
Next, they say that it is a fatal flaw to use birth
certificate info because birth certificates don't adequately capture intended place
of birth. But intended place of birth doesn't matter for this study - actual place of birth is what is most important. And the place of birth is adequately captured. The data used in these studies was only midwife attended births at home or at freestanding birth centers. As I said above, if it was unknown whether or not an attendant was present or
if there was no attendant at all, the data was not used. So again, their
second “flaw” with the article is yet again, not actually a flaw.
Then they say this "In recent
well-designed studies that captured planned place of birth and used better sources
of data, there were no differences in 5-minute Apgar scores between home and
hospital settings (Hutton et al, 2009; Janssen et al, 2009; van der Kooy et al,
2011)." How incredibly shocking!! Yet again, MANA is trying to prove a
point about safety by using studies based in other countries -- the first two
studies are out of Canada and the third is out of the Netherlands. How on earth
does this apply to the findings of these studies? IT DOESN’T. It literally takes nothing
away from the findings of these studies.
Finally they offer this "They analyzed the rare
occurrence of 5-minute Apgar scores of zero, which may be indicative of a
number of possible events which may or may not have been related to the time,
location or care provider at the birth. The authors note that stillbirths may
have occurred in the third trimester, may have been due to lethal congenital
anomalies, and other possibilities that are captured in a 5-minute Apgar score
of zero." However, if you read the study, they address this. And although it is considered a limitation that
antepartum deaths may be included, it likely wouldn't change the findings because intended home or birth center antepartum deaths would be transferred to the hospital for delivery. What midwife
would keep a woman at home to deliver the baby if she couldn't hear a heartbeat
at the beginning of labor?? The chances of any third trimester stillbirths
being included in the home birth group are slim to none.
That covers their critique of the studies. They were
grasping and officially grabbed onto nothing.
The fact is, these two studies are very high
quality. No, not perfect. But the findings should certainly not be dismissed.
They should be addressed. And they certainly should be considered for those looking into home birth.
****
So that’s that.
While home birth can
be safe, the truly safe scenarios are
the exception, not the rule. All evidence points toward an increase risk at
home. I have no doubt it is largely due to the lack of training and education
of the birth attendants.
I have more to say… including my thoughts on what
situations I would call “safe” for home birth and thoughts on the CPM/LM credential…
but I will end this particular post here. Stay tuned…
01/14/2013 Update:
I added a blog post addressing guidelines for having a safe home birth. Click here to read it.
01/14/2013 Update:
I added a blog post addressing guidelines for having a safe home birth. Click here to read it.
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