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:

#1 -- Outcomesof planned home births with certified professional midwives: large prospectivestudy in North America by Johnson and Davis, 2005, British Medical Journal

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:

Science Based Medicine: A Critique of the Leading Study of American Homebirth

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.

#2 -- Maternal and newborn outcomes in planned home birth vs planned hospital births: ametaanalysis by Wax, 2010, AJOG

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:

#3 -- Apgar score of 0 at 5 minutes and neonatal seizures or serious neurologic dysfunction in relation to birth setting by Grunebaum, 2013, AJOG

#4 -- Selected perinatal outcomes associated with planned home births in the United States by Cheng, 2013 AJOG

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.

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:

http://www.mana.org/blog/0/understanding-outliers-in-home-birth-research

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.

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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.

Induction versus Spontaneous

photo courtesy of drewesque

I wanted to write this blog post b/c I remember in my first pregnancy - toward the end - being so afraid (and peeved) when my OB brought up the topic of the possibility of induction. I was heavily influenced at that time with the many opinions I heard about not inducing, and to instead just wait for the babe to come ("there's no time limit," "there's no eviction notice," "don't choose your baby's birthday," etc) - the opinions/advice were by birth professionals I knew, people I trusted. I even repeated the advice to people I knew - people who trusted my opinion as a doula and childbirth educator. (makes me cringe) I have since heard too many stories similar to this story (or met women) whose unfortunate outcomes did not reflect that sentiment I had ingrained in my head: "baby will come when ready and not a moment too soon." Because that isn't true in every case. Even close monitoring does not guarantee complications are not developing (or that they won't develop closer to or during labor). So it left me questioning.... Is there a time when continuing on with a pregnancy becomes riskier than delivering? That's what inspired me to write this.... I was in search of evidence for induction vs spontaneous labor at or beyond 40 weeks.

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If you are approaching 40 weeks of pregnancy, you might hear your care giver bring up the topic of induction. If you are wondering why they are hoping the baby will come sooner, rather than later, this information may be useful to you. I know the idea of induction may be very scary. Perhaps reading evidence behind the recommendation will help you understand your professional care giver’s concern and help you make a more informed decision. Because ultimately, the choice is yours.

First, in October 2013, ACOG redefined what “term pregnancy” means. A woman who was “full term” previously meant she was anywhere from 37 to 42 weeks. Now, there are new definitions and “full term” is a shorter window.

The following represent the four new definitions of ‘term’ deliveries:

Early Term:  Between 37 weeks 0 days and 38 weeks 6 days

Full Term:    Between 39 weeks 0 days and 40 weeks 6 days

Late Term:   Between 41 weeks 0 days and 41 weeks 6 days

Postterm:     Between 42 weeks 0 days and beyond

From the study: “Babies born between 39 weeks 0 days and 40 weeks 6 days gestation have the best health outcomes, compared with babies born before or after this period. ”

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Here are several studies discussing labor induction vs expectant management (waiting for spontaneous labor). 41 weeks was the common “cut off” for induction in these studies.

Please note, in the studies you will see the term "expectant management." I was confused by the term initially so I want to add the definition. Expectant management refers to "watch and wait" for spontaneous labor. It is the "hands off" approach; as opposed to induction, which would be considered active management.

#1: http://www.ncbi.nlm.nih.gov/pubmed/17054226 (October 2006)

From results: 

"If deaths due to congenital abnormality are excluded, no deaths remain in the labour induction group and seven deaths remain in the no-induction group."

Conclusion: "A policy of labour induction after 41 completed weeks or later compared to awaiting spontaneous labour either indefinitely or at least one week is associated with fewer perinatal deaths. However, the absolute risk is extremely small. Women should be appropriately counselled on both the relative and absolute risks."

#2: http://www.ncbi.nlm.nih.gov/pubmed/22696345 (June 2012 -- I believe this is the updated version of the study above)

From the results:

"There was one perinatal death in the labour induction policy group compared with 13 perinatal deaths in the expectant management group. "

and

"Fewer babies in the labour induction group had meconium aspiration syndrome (RR 0.50, 95% CI 0.34 to 0.73; eight trials, 2371 infants) compared with a policy of expectant management. "

Conclusion:

"A policy of labour induction compared with expectant management is associated with fewer perinatal deaths and fewer caesarean sections. Some infant morbidities such as meconium aspiration syndrome were also reduced with a policy of post-term labour induction although no significant differences in the rate of NICU admission were seen.However, the absolute risk of perinatal death is small. Women should be appropriately counselled in order to make an informed choice between scheduled induction for a post-term pregnancy or monitoring without induction (or delayed induction)."

#3: http://journals.lww.com/greenjournal/Fulltext/2012/07000/Risk_of_Stillbirth_and_Infant_Death_Stratified_by.14.aspx (July 2012 -- Data used was from 1996-2006)

This study is about risks of delivery vs expectant management, and risk of stillbirth. It also took into consideration for those that delivered, what was the infant mortality rate - infant deaths of babies born alive that die before they turn one. 

Here is a graph from the study:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3719843/figure/F1/

Keep in mind the orange line is the expectant management group - this is the non-induction group. You can see the risk of stillbirth (red line) steadily rise from 37-40 weeks. Then increases more dramatically between 40-41 weeks, then even moreso after 41 weeks.

Results: The risk of stillbirth at term increases with gestational age from 2.1 per 10,000 ongoing pregnancies at 37 weeks of gestation up to 10.8 per 10,000 ongoing pregnancies at 42 weeks of gestation. At 38 weeks of gestation, the risk of expectant management carries a similar risk of death as delivery, but at each later gestational age, the mortality risk of expectant management is higher than the risk of delivery (39 weeks of gestation: 12.9 compared with 8.8 per 10,000; 40 weeks of gestation: 14.9 compared with 9.5 per 10,000; 41 weeks of gestation: 17.6 compared with 10.8 per 10,000).

Conclusion: Infant mortality rates at 39, 40, and 41 weeks of gestation are lower than the overall mortality risk of expectant management for 1 week.

#4: This was published in January 2013. It specifically addresses pregnant women that are 40 years of age and older.

http://www.rcog.org.uk/news/rcog-release-induction-labour-older-mothers-may-reduce-risk-stillbirth-say-experts

From the release: “Data from these studies show the risk of stillbirth at 39-40 weeks gestation is doubled for women aged 40 years or over, and at 39 weeks gestation these women (40+ years) have a similar stillbirth risk to women aged in their late 20s at 41 weeks gestation.”

and

“It is justifiable for experts to conclude that inducing labour at an earlier stage of gestation (39-40 weeks) in older mothers (40+ years) could prevent late stillbirth and any maternal risks of an ongoing pregnancy, without increasing the number of operative vaginal deliveries or emergency caesarean sections.”

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These are the studies I have found regarding this issue of induction vs wait for spontaneous labor. As you can see, because of the increase in stillbirth, especially after 41 weeks, it is no wonder why induction of labor is often recommended by 41 weeks. 

When deciding, it is important to compare evidence for one option versus evidence for another option. There will be anecdotes of those who went to 41, 42, 43+ weeks that ended with a healthy mom and baby, with no complications. But there will also be anecdotes of those who had elective inductions at 37 or 38 weeks that ended with a healthy mom and baby, with no complications. It does not mean either route is what the evidence supports as the safest route to go.

If you have any peer reviewed studies you’d like to add regarding this topic, please feel free to do so in the comments!

Edited 01/11/2013 to add another study:
#5: http://www.ajog.org/article/S0002-9378(08)00558-9/abstract

Results: Compared to infants born at 38, 39, or 40 weeks, those born at 41w0d to 42w6d have a greater odds of neonatal mortality (aOR: 1.34, 95% CI, 1.08-1.65). Subdividing by gestational week, infants delivered at 41w0d to 41w6d showed elevated mortality relative to earlier term births (aOR: 1.37, 95% CI, 1.08-1.73). Additional analyses support this increased neonatal mortality across all normal birthweight categories.

Conclusion: Infants born beyond 41w0d of gestation experience greater neonatal mortality relative to term infants born between 38w0d and 40w6d.