Is Home Birth In the US Safe?
February 27, 2014 8:42 AM   Subscribe

Statistics professor challenges midwives' math on home birth safety. This article includes links to multiple original sources so be sure to read (or scroll) to the end.
posted by the young rope-rider (277 comments total) 19 users marked this as a favorite
 
This is interesting, but I wonder if these studies take into account factors like age of the mother, certification and experience of the midwife, specific state and level of medical care in that state, etc
posted by roomthreeseventeen at 8:48 AM on February 27, 2014


I came for the article, I stayed for the comments.
posted by Ruthless Bunny at 8:50 AM on February 27, 2014 [4 favorites]


They're a comparable group of infants, but I don't know about state by state comparisons. CNMs are possibly less likely to do breech or VBACs at home than CPMs, and those are the types of births where the mortality rates were the most different.
posted by the young rope-rider at 8:55 AM on February 27, 2014


Ruthless Bunny, because I am an idiot I believed you and I read some of those comments.
posted by jeather at 8:56 AM on February 27, 2014 [6 favorites]


The conclusion from the statistician:

"So, for a comparable group of infants born in the hospital, with congenital abnormalities excluded, the combined neonatal and intrapartum death rate is at most 0.7 per thousand. The combined neonatal and intrapartum death rate for the MANA STATS group, with congenital abnormalities excluded, was 2.06 per thousand, which is significantly higher. (p<.0001, highly statistically significant.)

In other words, the expected number of deaths from causes other than congenital anomalies was at most 12, and the actual number of deaths was 35 (44 with anomalies included). It is clear that home birth substantially increases the risk of neonatal death and of intrapartum death."

That last sentence is not a valid conclusion from the premises.
posted by MisantropicPainforest at 8:57 AM on February 27, 2014 [1 favorite]


This is an apparent contradiction of the conclusion published in the Journal of Midwifery: "no concomitant increase in adverse events." That leaves the ultimate conclusion up to the reader of both analyses

"Up to the reader"? No. Somebody is right and somebody is wrong. I don't have the relevant expertise to decide, myself, but I'm pretty confident that the fact that these two papers disagree doesn't mean that the question is inherently undecideable and that we're left to construct our own reality.
posted by yoink at 9:00 AM on February 27, 2014 [36 favorites]


That last sentence is not a valid conclusion from the premises.

Why not?
posted by yoink at 9:01 AM on February 27, 2014 [3 favorites]


The Tuteur post comments section is actually pretty useful because she sticks around and answers some questions in the comments. She seems to have a pretty blunt affect dealing with her detractors and I got a big bogged down in the acronyms which probably make sense to moms and medical professionals. It also seems like one of the things that makes this comparison challenging is that there is a lot of missing data (particularly, it seems, from complicated at home births in which the mother was transferred to the hospital) and the sample sizes are small enough that if those turn out to be negative outcomes then home births are actually a lot WORSE than people already think they might be (as opposed to being maybe marginally better than people think they might be, but still not having better outcomes than hospital births).

I, too, found the "up to the reader" aspect of this sort of annoying. It just means we need more data or better analysis right? This isn't really an "on the one hand, on the other hand" situation. Stupid Gawker Media Empire.
posted by jessamyn at 9:01 AM on February 27, 2014 [5 favorites]


> I wonder if these studies take into account factors like age of the mother, certification and experience of the midwife, specific state and level of medical care in that state, etc

This is actually discussed in the "challenge" article, the "original source" mentioned above.

I don't have time to beat it up in detail, but I'd say, "Seems so."

Generally, midwives don't recommend home births for cases that they think are likely to result in complications, and in the cases with the worst complications like premature births, the mother is more likely to already be in the hospital, so IMHO there's already a systematic tendency for home birth pregnancies to be the "lower risk" ones.

This makes these results even more troubling - particularly for someone like me who has a tendency to support the idea of home birth.

Perhaps an ideal outcome of this would be some way to systematically identify conditions where home births have no greater risk than the hospital.

MisantropicPainforest:

> That last sentence is not a valid conclusion from the premises.

Could you give a hint as to your reasoning? The numbers seem to be right...?
posted by lupus_yonderboy at 9:02 AM on February 27, 2014 [2 favorites]


Also, from the shortened analysis on skeptical OB:

For babies born in a hospital during the period 2007-2010, weighing at least 2500 grams, whose mothers received some prenatal care, the neonatal death rate was 0.71 per thousand. When deaths due to congenital anomalies are excluded, the rate drops to 0.40. The neonatal death rate for MANA STATS babies was 0.77 excluding congenital anomalies (13 deaths out of 16,950 births) and 1.30 including congenital anomalies (22 total neonatal deaths). The neonatal death rate excluding anomalies was significantly higher in the MANA STATS group (p=0.01). In addition, the number of neonatal deaths attributed to congenital anomalies was higher than expected, although the statistical significance of this difference was marginal (p=0.04).

Really? This statistician is using p values and assumed normal distributions to test the significance of something that is so rare (13 out of 16950!) that three or four different observations would decide whether something is 'statistically significant'.
posted by MisantropicPainforest at 9:03 AM on February 27, 2014 [3 favorites]


The Skeptical OB has been all over this, of course, which I think is great. Very important discussion to be having.
posted by ThePinkSuperhero at 9:04 AM on February 27, 2014 [2 favorites]


The "up to the reader" aspect creates the impression in the reader that each of us gets to choose who is right for ourselves. We don't. This is the same hand-wavey woo that lets anti-vaxxers "do their own research and decide for themselves." Blergh.
posted by ambrosia at 9:04 AM on February 27, 2014 [6 favorites]


I did a lot of research on this about nine years ago leading up to a decision, along with my wife, to do a home birth. The only reason we could rationalize it was that we live in a city with two excellent hospitals that we can get to rapidly from where we live. As it happens, the birth happened in a hospital (not emergency related) after home birthing lingered an unacceptable amount of time, so we got the pleasure of paying for home birth and hospital fees.

What I recall most about the literature advocating for home birth is that it seemed to cherry pick comparing outcomes for the most healthy population. In retrospect I don't know why we made a fetish out of the birth experience. Hospitals have become much more accommodating and a Douala in the hospital improves things furthermore.

Looking back I feel a bit irresponsible and selfish. I'm not judging others, but for our next two kids we did hospital births.
posted by dgran at 9:05 AM on February 27, 2014 [13 favorites]


It is clear that home birth substantially increases the risk of neonatal death and of intrapartum death."

That last sentence is not a valid conclusion from the premises.

I agree. But I admit to being puzzled about what else might cause such a significant difference, considering that both breech and VBAC births would seem to be much safer when the resources of a hospital are immediately available.
posted by the young rope-rider at 9:06 AM on February 27, 2014


The difference isn't that significant really, when the base rate of the phenomenon being measured is so low.

Really though, the relevant and interesting question is, how do homebirths with certified nurse midwives fare vs. a hospital?
posted by MisantropicPainforest at 9:10 AM on February 27, 2014 [3 favorites]


My birth utopia would be birth centers adjacent to or within minutes of hospitals that are run very separately, and differently. You go there not for a medical experience but to birth a child in a homey- supportive atmosphere that considers emotional support a necessary element for many mothers giving labor (so is space if needed as well of course). It's decorated to be soothing and warm, there are essential oils, baths, pillows, choice of birthing postures and there's a lot more room for the mother to make choices about her experience outside of complications happening.

If complications arise the mother could (ideally) be transported through one of those connective paths up in the sky (you know what I mean? those are cool) to the hospital next door. There would be some amount of medical supplies and well trained nurses on site in the birth center as well to deal with certain emergencies immediately.

Both of my births had minor complications (and high stress circumstances around them) and I knew I wanted to be in the hospital. I was lucky with one birth to have a midwife and a doula with me in the hospital and it was a very different experience than being in a hospital with their traditional set up.

I really disliked the traditional setup even though I don't have any specific complaints about it other than that it was sterile, less supportive, and offered no choice of options about much of anything. I remember that they had some guy nurse in training who was basically there to watch and I was not asked about that at all. I feel like the lack of choice about that was really awful as in other settings I have been happy to offer myself to someone in training if they at least ask if I'm ok with that. There are so many things I don't like about hospitalized birth (through a very historically paternalistic ideology about birth and supporting or rather NOT supporting women through birth) that is part of the way hospitals tend to view and handle birth.
posted by xarnop at 9:12 AM on February 27, 2014 [12 favorites]


Really? This statistician is using p values and assumed normal distributions to test the significance of something that is so rare (13 out of 16950!) that three or four different observations would decide whether something is 'statistically significant'.

That was my thought as well. But, the Journal of Midwifery article uses the same type of analysis, though they say:

"It is difficult to compare birth-related mortality statistics across studies; there are so few death outcomes that statistical power is quite low. "

Which is why it is kind of up to the reader.
posted by bluefly at 9:13 AM on February 27, 2014 [2 favorites]


the relevant and interesting question is, how do homebirths with certified nurse midwives fare vs. a hospital?

For me the relevant and interesting question is how homebirths with certified nurse midwives far vs. hospital births also with a certified nurse midwife
posted by mcstayinskool at 9:14 AM on February 27, 2014 [2 favorites]


Xarnop,

come to Philadelphia! that's how it is at the Brwn Mawr birth center--a birth center staffed by the best midwives in the country, attached to a hospital in case there are any complications that require surgery.
posted by MisantropicPainforest at 9:15 AM on February 27, 2014 [3 favorites]


There's a really good birthing center right across the street from me in smalltown Vermont also.
posted by jessamyn at 9:16 AM on February 27, 2014 [2 favorites]


The reality of home birth in the US though is that it is not limited to CNMs, and multiple states give their stamp of approval to the CPM credential, which is significantly different, does not come with hospital privileges or prescribing power...
posted by the young rope-rider at 9:17 AM on February 27, 2014 [2 favorites]


Both of my daughters were born using certified nurse midwives, but at a hospital. In the case of my eldest, there was a small complication that required a doctor. If this were a home birth, it likely would have been a BIG complication. Our decision for both the nurse midwife route and the hospital route were both statistically driven.

My story is a single datum. But she's my datum and she's smart and beautiful and healthy. I feel exactly the same about home births as I did when we had her 10 years ago: no thanks.
posted by mcstayinskool at 9:17 AM on February 27, 2014 [4 favorites]


That last sentence is not a valid conclusion from the premises.

Why not?


Because the causality isn't demonstrated since the base rate is so low, invalidating the assumption that the phenomenon is normally distributed.
posted by MisantropicPainforest at 9:21 AM on February 27, 2014 [4 favorites]


Because the causality isn't demonstrated since the base rate is so low, invalidating the assumption that the phenomenon is normally distributed.

Oh, I see. You didn't mean that it was "not a valid conclusion from the premises" but that the premises were wrong. That's a rather different claim.
posted by yoink at 9:26 AM on February 27, 2014


So many things can go wrong with birthing. The desire to be in a "homey" environment...Is it really worth the death of the infant or the mother to have that?

I'm going to say no to that.

By all means, find the homiest hospital/birthing center you can, stand up for yourself and kick that male nurse that's making you uncomfortable, that's fine. But be somewhere complications can be dealt with.
posted by Windopaene at 9:33 AM on February 27, 2014 [2 favorites]


Is it really worth the death of the infant or the mother to have that?

Phrasing it this way isn't really doing anyone any favors.
posted by MisantropicPainforest at 9:37 AM on February 27, 2014 [5 favorites]


So what I get out of it is, home births are pretty safe, perhaps not as safe as hospitals but still pretty safe.
posted by edgeways at 9:40 AM on February 27, 2014 [2 favorites]


I like the idea of it, but I got a lot less positive after one of my crunchiest friends did it twice--and had serious complications both times. Even the non-fatal complications... have a habit of turning into things that often, for the mothers, can lead to very long-term problems. But it's not a dichotomy between needing to have a medicalized hospital induction-epidural-lay-on-your-back situation or doing it at home with just a midwife.
posted by Sequence at 9:43 AM on February 27, 2014 [4 favorites]


> So what I get out of it is, home births are pretty safe, perhaps not as safe as hospitals but still pretty safe.

Yes, and this is a reasonable conclusion to make, and I doubt anyone is saying that home births should be outlawed. This is happening because the Midwives Alliance of North America made the claim, based on these same figures, that home birth is just as safe as hospital birth, and it seems that claim was begging for a rebuttal.
posted by savetheclocktower at 9:44 AM on February 27, 2014 [6 favorites]


Is it really worth the death of the infant or the mother to have that?

No one said that. And we're not talking "homey" we're talking AT HOME which is a big difference. Not getting in a car, being able to have as many friends and family around as you want, not having to get childcare for your other children, having the only rules being the ones set up by you and your midwife/nurse/doula/etc. not getting pressured into any interventions that may be against your birth plan just for someone else's convenience and not for any medically necessary reason, getting to choose who is attending at the birth, not getting charged for items you own, etc.

There are good arguments for home births as well as good indicators for when they are not as good an idea. The general point of TFA is that there are always risks in childbirth no matter what. Giving people to tools to determine whether the level of risk is acceptable to them is a bit of a cottage industry in which people still disagree. However some of it comes down to the fact that people are terrible at risk assessment (or do morning-after quarterbacking) and internet people like to blame other people for things that go wrong and prefer black and white decision trees and not shades-of-grey risk tolerance assessment.
posted by jessamyn at 9:44 AM on February 27, 2014 [18 favorites]


I then compared MANA STATS numbers to CDC numbers using an alternate hypothesis of increased death rates against a null hypothesis of equal or lesser death rates. Due to the small numbers, I computed p-values directly, with the binomial formula, rather than a normal distribution.

Actually, I take back my comment. Dr. Orosz computed the p-values directly; she didn't use a normal distribution approximation. I think the number of deaths is still pretty low for the p-values to mean that much.
posted by bluefly at 9:44 AM on February 27, 2014 [1 favorite]


and kick that male nurse that's making you uncomfortable

I am going to gently inform you that CNMs can be male too, so your insinuation is not only extremely obnoxious but completely misinformed.
posted by Wordwoman at 9:45 AM on February 27, 2014 [12 favorites]


The "up to the reader" aspect creates the impression in the reader that each of us gets to choose who is right for ourselves.

If your goal is pageviews, I think that aspect makes a lot of sense. I'd like to thank everyone in this thread for the direction and interesting nature of the comments as opposed to the ones at io9. It's disappointing to me that a site ostensibly for nerds could have a commentariat that dense.
posted by yerfatma at 9:48 AM on February 27, 2014


not getting pressured into any interventions that may be against your birth plan just for someone else's convenience and not for any medically necessary reason

This is why I had midwife-assisted home births with both of my children. A few minutes' drive from the nearest hospital in case of emergency. Knowing that it takes 30 minutes for the operating room to be prepared, whether I'm having the baby at home or in the hospital.
posted by Dragonness at 9:51 AM on February 27, 2014


I'm reminded of this comment from an earlier thread on Symphysiotomy.

"Some women are so traumatized by their hospital births that they end up taking the greater risk of birthing at home, unattended (if they can't find a midwife willing or able to take them) just to avoid the hospital. Birth is a uniquely vulnerable time for women, and there are many who feel violated and hurt even if they come out ostensibly healthy with a healthy baby."

So not every healthy hospital birth is a positive experience. A healthy birth on paper may have involved avoidable interventions that caused physical and/or emotional damage to both mother and baby. You can't blame mothers who have gone through such an experience for looking for alternatives to a "healthy" hospital birth.
posted by Otis at 9:55 AM on February 27, 2014 [6 favorites]


Would they prep the operating room on your midwife's say-so? Also, wouldn't you need to be prepped? My understanding is that they have to do a lot of stuff that requires you to be physically there, like finding your blood type, determining your anaesthesia needs, getting your informed consent...in contrast, an OR in the L & D section is pretty much always set up and ready for urgent surgeries.

I suppose that varies by hospital, though, as my experience was with a huge teaching hospital and they said they could get a c-section started in a matter of minutes if necessary. Of course, I was close to needing one and all the operating rooms on the floor were full...
posted by the young rope-rider at 10:01 AM on February 27, 2014 [2 favorites]


Let's accept for the sake of argument that home births are, all else being equal, somewhat more risky than hospital births. I don't know if this article proves that (the "all else being equal" part seems particularly difficult to establish) but let's just take it as given for the moment. Why then does it follow that we should therefore try to prevent home births? Why not work to close the gap instead?

To me it shouldn't be a matter of "home births are riskier than hospital births, and therefore we should try to stop women from giving birth at home." Instead the response should be "home births are riskier than hospital births, so since many women obviously would prefer to give birth at home what can we do to lessen that risk?"

This seems obvious to me, but I never feel like that's the direction that the discussion is going on this particular issue. I don't have any stake in the argument, but that part doesn't make sense to me.
posted by Scientist at 10:03 AM on February 27, 2014 [11 favorites]


> Would they prep the operating room on your midwife's say-so?

Yes, that was my understanding.
posted by Dragonness at 10:04 AM on February 27, 2014


Wordwoman, that comment was a response to a specific comment earlier in the thread. It wasn't a generalization about males attending births.
posted by rabbitrabbit at 10:11 AM on February 27, 2014


"home births are riskier than hospital births, so since many women obviously would prefer to give birth at home what can we do to lessen that risk?"

A lot of people do think this way, in fact. However, home birth attendants are not all under one governing body, and there are a patchwork of laws governing them at the state level.

In contrast, some countries have one home birth system with one standard of care, based on evidence. That means that virtually all midwifes in that system will transfer care to an obstetrician given certain risk factors. They are all adequately trained in neonatal resuscitation and the use of medications for hemmorage. These are just a few standards, of many, that would make home birth consistently safer.

But how would you propose that we impose those kinds of consistent standards here in the US?
posted by the young rope-rider at 10:18 AM on February 27, 2014 [1 favorite]


And that comment wasn't about males attending births but about having someone there for training without the mother's consent.
posted by MisantropicPainforest at 10:18 AM on February 27, 2014 [3 favorites]


I think it was attempting to say women shouldn't have any say over who attends their birth or what happens at their birth, no matter how much it causes trauma or difficulty for the woman (which ironically also increases risk of complication and death for infants because stress hormones don't mix with a smooth birth very well).

Not anything about males at birth; if anything it sounds like an attempt to say women should not be allowed a gender preference at who will be staring between their legs for hours at a time, which I disagree with unless there is an emergency reason such a request can't be accommodated.

There are plenty of people who have involuntary stress responses to males due to PTSD issues and adding that complication to a birth is something I think should notbe done without consent of the person attending, not to mention people can just feel a really bad connection with various birth attendants for any reason and being able to meet who will be at the birth in advance and have some say in it, to me, an important aspect of client centered birth whether in a hospital, birthing center OR home.
posted by xarnop at 10:18 AM on February 27, 2014


The difference in mortality between home-birth and hospital-birth that this single-data-source, single-country, small-numbers analysis finds (if it is accurate which is not particularly likely given the numbers) is a fraction of the difference in mortality from using public transit over the life of a child instead of using a car.

Should parents of children be allowed to choose to use cars? I'm actually not being entirely sarcastic with this question -- I looked a lot into the numbers associated with transportation when I had my child and have consequently developed some fairly radical opinions.
posted by lastobelus at 10:34 AM on February 27, 2014 [5 favorites]


Hospitals have become much more accommodating and a Doula in the hospital improves things furthermore.

The problem is, most hospitals have NOT become much more accommodating. Some have, and that's great, but many more have not. And doulas are great (disclaimer: I am one) but many women cannot afford them. In many cases, you head into the hospital for that safer birth and are hurried along, possibly pressured into "consenting" to unnecessary interventions for both yourself and baby (often without ever hearing the facts), and likely being treated in ways that are not evidence based (hello directed pushing). My problem with articles like this is that they stop at "ok, great! hospital safer! done! end of story!" when in fact, the end should be "So, based on these numbers the hospital appears to be safer, but people are having bad experiences there and feel the need to go elsewhere to avoid hospitals. Let's see what we can do to address that--by making home birth safer, or by making the hospital a better (psychologically safer, can we say?) place to give birth, or, ideally, BOTH! Wouldn't that be great--more than one safe, evidence-based, empowering, positive option for where to give birth! I wish everyone could work together towards that outcome, instead of fighting about which one option is better than the other.

In Canada, midwives are now recognized and registered on the national level. They must all complete the same level of training (there is a bridging program for providers trained outside of the current system) and their clients can have home, hospital, or birthing centre (if locally available) births. The system is still fairly new and it's not without problems, but personally I'm a huge fan. Women should have reliable access to the midwifery model of care, and should be equally as confident in the education of their midwife as in the education of their OB. I hope that some studies similar to this one will be forthcoming in Canada over the next few years, because a comparison of outcomes which did not have the significant confounding factor of HIGHLY variable training among US home birth providers would be much more credible to me.

But mostly, I wish folks on both sides of this issue could put aside their differences and work together to make birth better for all women, no matter where they want to do it. Period! No skepticism required.
posted by snorkmaiden at 10:37 AM on February 27, 2014 [21 favorites]


This discussion really, really needs to be put in this context:

How the United States Compares with Europe

The difference this analysis found in mortality rates IN THE US between hospitals and homebirths is somewhat smaller than the difference in mortality between the US and the rest of the developed world.
posted by lastobelus at 10:40 AM on February 27, 2014 [10 favorites]


possibly pressured into "consenting" to unnecessary interventions for both yourself and baby (often without ever hearing the facts)

Yeah but at least someone's making a metric fuckton of money on these interventions! /s
posted by MisantropicPainforest at 10:44 AM on February 27, 2014 [2 favorites]




Had a potential client contact me a few months ago looking for help. His wife was giving birth to their third child, and they elected to homebirth with some homebirthing company run by a physician and midwife. Mom gave birth and physician began taking care of baby. Midwife looked over mom. There was lots of bleeding and mom began to panic and asked to go hospital, but midwife kept telling them everything was normal and there was nothing to worry about.

Neither of these home birthers knew how to or could diagnose or treat a retroplacental hemorrhage. Wife was in and out of consciousness and finally was unresponsive as she went into shock from loss of fluid. Despite being told by midwife not to do so, Husband finally called 911 and an ambulance came. Vitals were non-existent due to loss of blood. Even when paramedics immediately recognized the obvious signs of distress and reacted urgently, midwife kept telling husband that everything was going to be ok and the medics were over-reacting. Paramedics remarkably kept mom alive to the hospital, where she began a long, protracted course that ended weeks later with the withdrawal of life-sustaining treatment.

Husband incurred a lot of medical bills for his wife's care, and ultimately lost wife. Kids, including newborn, lost their mom. Husband now needs to hire help to care for the kids so he can work. Whole family is destroyed.

And... get ready for this.... these home birth providers don't carry any insurance. So, family has no recourse and we can't help them.

Whenever I hear people advocating for homebirth, frustration wells up inside of me and I have to try to keep myself from saying how ill-advised, short-sighted and risk-oblivious their position is. With all of the things that can wrong in a birth, you want to be at the best hospital you can get to just in case... not just for the mother's well-being, but the baby's as well. I can't even begin to tell you how many times I have seen cases where babys born in world class hospitals developed CP or periventricular leukomalacia or some other profound injury because of problems with the birth and immediate neo-natal care. If these things can't be treated in world class hospitals, what in the world are you going to do in your home? Whatever benefit there is from homebirth, it is not worth the risk.
posted by dios at 10:46 AM on February 27, 2014 [13 favorites]


dios,

We can exchange anecdata all you want, but every nurse I know who works on L&D has dozens of horror stories such as yours. But the fact of the matter is is that the mortality rates aren't significantly higher for homebirths, and that is what is important. Not anecdotes.
posted by MisantropicPainforest at 10:52 AM on February 27, 2014 [5 favorites]


@snorkmaiden

A couple more things about Canada: the midwives and OB's seem at least in our case to be very willing to work with each other.

We had a risk factor which necessitated switching from midwife to OB. Late in the pregnancy that risk factor was ruled out, and our OB outlined for us that she felt it would be a perfectly valid choice to go back to a home birth plan if we wanted to. Then, we went to hospital 48 hours after water breaking and no labour -- and they sent us back home after establishing there was no indication of meconium or heart rate issues (they had a really good baseline because of heart rate monitoring from the separate issue early in the pregnancy). After another 24 hours and no labour, we returned to hospital as indicated, and prostaglandin got things started.

The whole way along the OB, midwife, and hospital worked together as a team, with none of the poo-slinging that seems to characterize the discussion in the US. They treated us as conscious participants making informed risk decisions, gave us data, gave us choice and encouraged the low-intervention route but while being aware of when intervention should actually be warranted. It was a very positive experience, even though it did end in a hospital. But the ending in a hospital was PART of the home birth plan. The home birth plan INCLUDED "transfer to hospital if x, y, z"
posted by lastobelus at 10:53 AM on February 27, 2014 [4 favorites]


This discussion really, really needs to be put in this context:

How the United States Compares with Europe


Infant mortality in the US is horrific. However, it is not comparable to intrapartum mortality. They are completely different measures.
posted by the young rope-rider at 10:53 AM on February 27, 2014


dios, that is an extremely sad story. But is it a sad story about home birth, or a sad story about provider error (whether because providers were not educated correctly, or incompetent, or just made a mistake that day)? Based on my reading, it is the latter, and the way to solve that problem is not to demonize home birthing, but to ensure access to well-educated, competent providers for home births.
posted by snorkmaiden at 10:54 AM on February 27, 2014 [3 favorites]


MP: "But the fact of the matter is is that the mortality rates aren't significantly higher for homebirths, and that is what is important."

From TFA:
So, for a comparable group of infants born in the hospital, with congenital abnormalities excluded, the combined neonatal and intrapartum death rate is at most 0.7 per thousand. The combined neonatal and intrapartum death rate for the MANA STATS group, with congenital abnormalities excluded, was 2.06 per thousand, which is significantly higher.
posted by norm at 10:55 AM on February 27, 2014 [4 favorites]


@lastobelus, that sounds AWESOME. I dream of that being a reality everywhere! I'm in Canada too, and I'm sad to report that in the provinces I have first hand experience with (beginning with S and Q), some poo is definitely still being flung, and lots of parents are sitll not treated as respectfully as you were. But progress is happening, and I'm hopeful about it.
posted by snorkmaiden at 10:57 AM on February 27, 2014


Statistics are not simple in this matter. There are huge regional differences, even within smaller countries/states, and some of the factors one rarely sees in this endless discussion are: distance to hospital (when giving birth at home), income level, insurance coverage and family conditions.

A friend recently gave birth at home in spite of a lot of risk-factors. But she lives 500 meters from the main university hospital in the country and had a university-educated midwife with her all the time. Another friend worked as a midwife in a rural hospital where doctors were only on call. The women would come in, give birth and be out again within 6 hours, not caring much about the design features of the delivery room, but also having a lot less access to emergency care than my friend living in the city. Also, the rural women were often busy, having families to feed and cows to milk.

Since I live in a country with socialized medicine, there is no way anyone will be allowed to deliver out of the hospital if they aren't judged healthy enough. And "healthy" applies to psychological and social health indicators as well as physical. Thus, there is no statistically significant difference in mortality between home-births and hospital-births here.

But why do people get so angry about this? Obviously, a choice of this importance needs to be informed, and I believe there needs to be legal standards for home-births as well as hospital births, but at the end of the day, it must be up to each family what they would prefer to do. I stopped at two children, but had there been a third, I would have gone for home-birth if possible. Already at no. 2, nothing was complicated and the stress of getting to the hospital and back was much worse than actually popping out the baby.
posted by mumimor at 10:58 AM on February 27, 2014 [1 favorite]


We gave a "Family Doctor", who handles The Wife's Healthcare, too. She delivered both our babies. Her practice is run in such a way that we felt we had all the advantages of 100% Hippie Birth, but with the additional risk management of a full on surgical suite just down the hall. If needed.

tl;dr: If you don't LOVE your OB, shop around.
posted by mikelieman at 10:59 AM on February 27, 2014 [1 favorite]


Oh, and if you give birth at home, guess who has to do the cleaning afterwards. HINT: It's not the new mother.
posted by mikelieman at 11:00 AM on February 27, 2014


Based on my reading, it is the latter, and the way to solve that problem is not to demonize home birthing, but to ensure access to well-educated, competent providers for home births.

I would be thrilled if I felt this was possible or even in the works in a serious way. It feels like much of the lobbying surrounding home birth attendants is towards giving more freedom to undereducated providers.

I have a hard time refraining from critique of the here-and-now because another, better system would be okay.
posted by the young rope-rider at 11:00 AM on February 27, 2014 [2 favorites]


Fortunately for many parents, if you just do a little research you'll find that an increasing number of American metro areas have at least one hospital that incorporates midwifery and a whole host of flexible birthing plans into their own on-site OB ward. What that means is basically, you can have a "home birth" style delivery right there in a comfortable suite in the hospital (with yoga balls, a tub, whatever you want) with your midwife, doula, or whatever...and in the statistically unlikely but always possible event that there are extreme complications you have the entirety of 21st century medicine right outside the door ready to intervene at your say so.

I talk to other new parents about this stuff all the time and they NEVER seem to realize how common it is! It's like when you realize all your friends don't know about FSAs for dependents that are already part of their insurance. Come on folks. Do your due diligence, the whole baby thing is a pretty significant project to embark on.
posted by trackofalljades at 11:02 AM on February 27, 2014 [1 favorite]


We can exchange anecdata all you want, but every nurse I know who works on L&D has dozens of horror stories such as yours.
posted by MisantropicPainforest at 12:52 PM on February 27


I'm not suggesting homebirth is bad because of what happened to this person. But the second part of the sentence makes my point for me: the process of giving birth is filled with horror stories even at hospitals designed to deal with them as it is a very serious event both for the mother and the baby. So a person who is adequately competent at risk assessment should ask themselves, which of the two places--a hospital or my house--is more adequately suited to address the issue should one of these "horror stories" occurs? There can be no serious argument on that front.

If mom is giving birth and mom gets an amniotic fluid embolism from a simple hair cell getting into the blood stream from the placenta, mom is very likely to experience an awful and quick death. Baby is at risk for brain damage. And those things are unpredictable, and unless you get amazing emergency treatment and a whole lot of luck, mom will die and baby can be profoundly injured. Get one at a home birth? Bye-bye; you will die. At a hospital? You have a long shot. And this isn't some "anecdata." It is the 5th most common cause of maternal death. It is known and should be factored into the analysis. If you don't consider it, then you are incompetent at risk analysis.
posted by dios at 11:04 AM on February 27, 2014 [5 favorites]


@snorkmaiden There WAS some poo-slinging at some meetups we attended. But none at all among the group of health professionals we actually worked with.
posted by lastobelus at 11:04 AM on February 27, 2014


But is it a sad story about home birth, or a sad story about provider error (whether because providers were not educated correctly, or incompetent, or just made a mistake that day)? Based on my reading, it is the latter,

It is a sad story about home birth. You're going to get some degree of complications and provider error either way, but at home there are no doctors within reach.
posted by Pruitt-Igoe at 11:05 AM on February 27, 2014 [1 favorite]


What that means is basically, you can have a "home birth" style delivery right there in a comfortable suite in the hospital (with yoga balls, a tub, whatever you want) with your midwife, doula, or whatever...and in the statistically unlikely but always possible event that there are extreme complications you have the entirety of 21st century medicine right outside the door ready to intervene at your say so.

I had one birth in a hospital affiliated birth center such as you describe, and one birth at home (after our hospital-adjacent birth center turned out to be full when I went into labor.) They could not have been more different. One of the factors that led to me choosing to deliver at home with the second birth was that I have extremely quick labors, and the journey to a different facility would have meant an hour on the road. . . the entirety of that labor, from the ROM that started to real labor to when I was holding my son, was 78 minutes. There is no circumstance where a home birth is worse than a side-of-the-road birth, and I felt like that was a real possibility.

BUT I live in a state that has extremely strict credentialing requirements for midwives; they're allowed to carry oxygen and pitocin, they have their own well-defined and well-regarded scope of practice, and they have a lot of practice handing off to hospitals in transfer situations. It would be different somewhere else.
posted by KathrynT at 11:07 AM on February 27, 2014 [2 favorites]


@dios

A couple things:

1. Awareness of what factors indicate a transfer to hospital are necessary are very important. In Canada this is now regulated, and is part both of midwives' training and their legal responsibility.

2. The other side of the coin is excessive intervention. What people often forget is that interventions themselves have a risk. So, while they dramatically reduce the risk when they are warranted, they can increase risk when they are not warranted. A large part of what has driven the home-birth movement is excessive intervention.
posted by lastobelus at 11:08 AM on February 27, 2014 [2 favorites]


But the second part of the sentence makes my point for me: the process of giving birth is filled with horror stories even at hospitals designed to deal with them as it is a very serious event both for the mother and the baby. So a person who is adequately competent at risk assessment should ask themselves, which of the two places--a hospital or my house--is more adequately suited to address the issue should one of these "horror stories" occurs? There can be no serious argument on that front.


No it doesn't, because many of the horror stories I hear from nurses in hospitals are along the lines of: "they pressured her into a c-section she didn't need", "they were complete dicks to her", "the mother has a history of sexual abuse and the OB didn't give a shit about that or adjust his behavior accordingly", "the anesthesiologist pressured the mother into taking pain meds that she didn't need". These things are omnitpresent in hospitals.
posted by MisantropicPainforest at 11:09 AM on February 27, 2014


But why do people get so angry about this? Obviously, a choice of this importance needs to be informed,

I get angry sometimes because I don't think people are actually informed. See upthread, where the US's high infant mortality rate is referenced. This is used all the time as an argument for hospital birth being dangerous for the baby, even though it is not really applicable.

I also personally get angry at professional organizations that purport to maintain decent licensing standards for their members, but in actuality serve as glorified lobbying groups. MANA, afaik, is pretty irresponsible in this way. They're effectively exploiting women's trust in their competence and good faith, and I hate that. I have similar feelings about MDs and their frequent failures to police their own. Although at least they have malpractice insurance...
posted by the young rope-rider at 11:12 AM on February 27, 2014 [7 favorites]


But is it a sad story about home birth, or a sad story about provider error (whether because providers were not educated correctly, or incompetent, or just made a mistake that day)? Based on my reading, it is the latter, and the way to solve that problem is not to demonize home birthing, but to ensure access to well-educated, competent providers for home births.
posted by snorkmaiden at 12:54 PM on February 27


It is provider error. But it is a sad story about home birth, as well. Because there are no home birth providers who carry around the necessary equipment to diagnose and treat retroplacental hemorrhages. So it's not like any other ones would have done much better. Maybe they would have called 911 faster and maybe mom would have survived if that occurred, but mom could also have had a hypoxic brain injury in the interim. Regardless, these limitations would not exist had mom been in the hospital.

You suggest I am demonizing home birthing, and I don't know how to respond to that. My point is simply this: the home is not a place equipped to handle the type of foreseeable outcomes that occur. I wouldn't perform surgery in my home either. When you are doing something where there are known and quantifiable risks, you ought to be at the place best suited to handle those risks. I suppose one could argue that you should be able to rent all these fancy machines and things we have at hospitals and have teleradiologists on standby to read films and make diagnoses, but seems to me we already have places for that. And my view is that in assessing risk you should be at the place that reduces those risks. I am not demonizing the reasons or beliefs of those considering or advocating home births. I just view it as reckless and ill-advised in light of the risks.
posted by dios at 11:12 AM on February 27, 2014 [7 favorites]


I get angry sometimes because I don't think people are actually informed.

I have similar feelings about MDs and their frequent failures to police their own. Although at least they have malpractice insurance...


So do certified nurse midwives.
posted by MisantropicPainforest at 11:14 AM on February 27, 2014


@the young rope-rider

Sorry can't find intrapartum numbers specifically comparing the US with social democracies. But intrapartum deaths are a fairly big slice of the perinatal mortality pie. I didn't say perinatal death comparison between the US and social democracies rendered the whole discussion invalid, just that it should properly be part of the context of the discussion.
posted by lastobelus at 11:17 AM on February 27, 2014 [1 favorite]


@young rope-rider, I don't mean for us to not critique the here-and-now, but to choose the correct issue to critique.

I know that there are folks out there lobbying for more freedom to under-educated providers, and I think that's wrong... but I also think part of why those folks feel the way they do is because of this unreasonable good-vs-evil narrative that both sides have got going on around home birth. We should be finding our common ground and critiquing the here-and-now together. I think it should be possible for that to happen, and at the minimum, I think it's important not to work at widening the divide between the two sides of this debate.

@dios, my suggestion is that the whole rhetoric around this issue demonizes home birth, and misidentifies practitioner error problems as home birth problems. There may be some cases where home birth is the problem, and I agree that we should all be aiming to avoid those, but I do not think that ruling out home birth absolutely is the answer. I am not a medical professional and don't know about what other outcomes could have been possible in the case you described; I'm just very aware that whenever this argument takes place, I always, always hear someone say "look, this home birth practitioner attended a birth with a bad outcome--that means home birth is bad." But in fact instead of going straight to that conclusion, I think it's important to ask whether there was provider error involved? whether this case was not suitable for home birth and could have been prevented that way? whether this same outcome might have occurred in the hospital as well? and many other questions. I believe that "this bad outcome = all home birth bad" thinking is also ill-advised.
posted by snorkmaiden at 11:24 AM on February 27, 2014


A large part of what has driven the home-birth movement is excessive intervention.

and

"they pressured her into a c-section she didn't need", "they were complete dicks to her", "the mother has a history of sexual abuse and the OB didn't give a shit about that or adjust his behavior accordingly", "the anesthesiologist pressured the mother into taking pain meds that she didn't need".

If this is where this argument is headed, we are basically heading into anti-vax territory.

I suggested before, in my view, that the decision should be a risk assessment. And if one side argues for home birth because of a concern of getting unnecessary pitocin or getting "pressured into" pain medication as if that is an equivalent risk to getting, for instance, the known condition of an amniotic fluid embolism at a home birth, then this not an argument that is going to be resolved with statistics or science because one side of the argument is not based on it.
posted by dios at 11:24 AM on February 27, 2014 [7 favorites]


lastobelus, the paper you linked to concluded that the real problem in the US is too many premature births. I have no idea wether this is a correct conclusion, but it might point to the fact that there is generally a lot more focus on mothers' health here in Europe than in the US. Meaning that home-birth or not is the least of problems in this context, since it is more about mothers getting insufficient care and advice, working too hard, being overweight and/or diabetic.
Makes me think that political crusades against home-births might be there to distract from the real issues...
posted by mumimor at 11:25 AM on February 27, 2014 [2 favorites]


If this is where this argument is headed, we are basically heading into anti-vax territory.

Oh come on! This statement basically prevents me from operating under the assumption that you're a good faith participant in this conversation.

And if one side argues for home birth because of a concern of getting unnecessary pitocin or getting "pressured into" pain medication as if that is an equivalent risk to getting, for instance, the known condition of an amniotic fluid embolism at a home birth, then this not an argument that is going to be resolved with statistics or science because one side of the argument is not based on it.

They are not equivalent risks, they are more risky because they are MUCH more likely to happen in a hospital than a home birth or a birth center. and despite your scare quotes, they are real things that happen every day in hospitals.
posted by MisantropicPainforest at 11:31 AM on February 27, 2014 [1 favorite]


this not an argument that is going to be resolved with statistics or science because one side of the argument is not based on it.

That's not true, nor is it fair. It is possible for two people to compare a large risk of a bad thing against a much, much smaller risk of a much, much worse thing, and come to different conclusions. (And choosing an amniotic fluid embolism as your benchmark isn't really appropriate, because those are virtually unsurvivable no matter where they happen.)
posted by KathrynT at 11:32 AM on February 27, 2014


@dios No rational person making a statistics-based risk decision is going to be an anti-vaxer given the data we have available. Birth interventions are an entirely different thing. C-sections have risks, both short and long-term, for both infant and mother. There is a LOT of evidence that c-sections are being performed in cases where the risks associated with c-sections are LARGER than the risks with natural births. You're just poo-slinging. You're trying to say that I'm "like an anti-vaxer" because I support (safe, regulated, informed) homebirth. Sorry, but that's bullshit.
posted by lastobelus at 11:32 AM on February 27, 2014 [16 favorites]


I never know what to make of these sorts of statistics, because, like so many things, it depends. Are the midwives properly qualified? Are they doing a good job of filtering out high-risk pregnancies, including pregnancies that become high risk later in the term? Do they know their limits should something start to go wrong during the birth? Or are they taking risks that they should not be? My understanding is that for low-risk births, with well-trained midwives, a midwife delivery is no more hazardous than a hospital delivery.

Certainly any competent midwife in the scenario dios describes above should have called 911 for a transfer to the hospital at the first sign of serious complications. But doctors and nurses make mistakes, too. And hospital births are medicated to an extraordinarily unnecessary degree, with pressure often put on women to have epidurals and C-sections basically to make doctors' lives easier. In South Africa, something like 97% of births are by C-section, because doctors can just do one after another and they don't have to wait around.

And then there's the risk of superbugs in hospitals. I know of a woman who gave birth in the hospital, only to have her baby contract a superbug and almost die. The child is now allergic to just about everything. For her second baby, she gave birth at home, without problems.

This mom made an interesting observation: if you go to the hospital, and your baby gets a superbug and dies, no one will blame you. But if you decide to have a home birth, and something goes wrong, and your baby dies, everyone will blame you. Again, some hospitals are better than others at infection control, just like some jurisdictions do a better job of licensing and supporting midwifery. There isn't one right answer in every place.
posted by Dasein at 11:35 AM on February 27, 2014 [5 favorites]


this not an argument that is going to be resolved with statistics or science because one side of the argument is not based on it.

I assure that our decision to pursue a homebirth very much involved a fuckton of research into statistics & comparative studies. I geek everything I do, and my partner is similar; the birth of our son was no exception. Then we had an early indication of possible placenta previa; that involved a whole other fuckton of research. Our OB helpfully printed us off a inch-thick stack of studies that would otherwise have been behind paywalls. So here, have your poo back.
posted by lastobelus at 11:37 AM on February 27, 2014 [1 favorite]


The unspoken issue underneath much of this discussion is the reality that the mother and the full-term fetus have significantly divergent interests. It's not enough to weigh the risks to baby. It's also not enough to gloss over them. They exist, but so do risks to the mother, and those include the risks of surgical births. Justified or unjustified, c-sections carry risk.

There is no simple answer.
posted by the young rope-rider at 11:38 AM on February 27, 2014 [1 favorite]


My letter in testimony of An Act Relative to Certified Professional Midwives, a bill in MA to license homebirth midwives:

"Dear Senator Keenan and Represantive Sanchez,

I am writing to you in support of An Act Relative to Certified Professional Midwives (Bill numbers HB 2008 and SB 1081). I am also forwarding my letter to my own officials, Representative John F. Keenan of Salem and Senator Lovely. Suffice it to say, I chose homebirth for my second child after first taking the risk of the hospital. My particular story is long and sordid and involves a lot complications that included but were not limited to:

*A long 40 labor during which I was left nearly completely alone by hospital staff and only seen my OB three times.

*A c-section with failed anesthesia and instead of being put out, I was left to experience the pain in shocked silence

*A nurse in the post-partum ward who confused my records with that of another patient’s

*A care provider who did not believe that I was consistently experiencing pain months later

*Subsequent Post Traumatic Stress Syndrome and Post Partum Depression antecedent to the PTSD.

When my son was ten months old, I had an appointment with another OB/GYN at another hospital who took my physical pain seriously, and when she couldn’t locate the source of it, she referred me to an OB/GYN with a specialization in pelvic pain. This OB/GYN scheduled me for a larascopic procedure to see if scar tissue might be the problem, and in the meantime prescribed me lidocaine patches to see if that would take the pain away. They did, so I didn’t need an additional surgery. When I called the OB/GYN who delivered my son to inform them how my pain had been mishandled, I was treated dismissively.

What I was saying couldn’t have possibly been true.

Given all that we had been through --- what my family had been through --- I vowed never to have more children.

A report on the increase of home births found that, “Women who are married and have already had a child are also more likely to have a home birth,” and Professor Eugene Declercq of Boston University who assisted in this analysis is quoted in and NPR as saying, "It may be that older mothers who have had the experience of having had a hospital birth may want to have the experience of having a home birth because of whatever they experienced in that first birth.” (http://m.npr.org/news/Health/145880448)

I can attest this was certainly my situation.

When I became unexpectedly pregnant in early 2011, my world was shaken. I thought very hard about having an abortion, because I didn’t know that my family deserved to go through what we had been through again when I was finally in a place where loving my son was easy and not something I cried about not being able to do. And this in part where choice --- the right of a women to choose --- comes into play. The Commonwealth of Massachusetts protects the rights of women to choose if they wish to have a baby or not after becoming pregnant.

Doesn’t it make sense we not only protect the right to choose or not to have a baby, but protect those women who choose to have a baby by passing HB 2008 and SB 1081? HB 2008 and SB 1081 will require Certified Professional Midwives to meet competency standards in order to practice homebirth midwifery. Every other category of professional related to prenatal care, birth, perinatal care,
and post-partum care are licensed by the state. These include OB/GYNs, Certified Nurse Midwives, pediatricians and family medicine practitioners. The same consumer protections afforded women who choose to birth in hospitals or birth centers should be available to women who choose to birth at home. If the groups opposing this bill are opposed to the dangers of homebirth, then I ask, why not make it safer by regulating the profession of Certified Professional Midwives?

I told my husband I could never go to a hospital again. Indeed, in those two years since having my son, stepping foot in any hospital for any reason led to my pulse racing, my vision going blurry, and near panic attacks. I’d have to stop and remind myself I was not on a gurney. I’d have to physically touch my legs to make sure I was standing. I’d have to breathe deeply and let the flashbacks play while doing as

I could to remain in the present. These things? These reactions? To simply stepping foot in a hospital to visit someone, for a routine appointment, for anything? If this was my experience for the ordinary, what about during labor? I had lost so much, risked so much when I chose to have my first baby in the hospital. So when I finally came around to having this second baby instead of an abortion – when I learned because of my c-section, I couldn’t birth in the Cambridge Birth Center or the North Shore Birth Center, a middle ground option between the hospital and at home -- I had no choice really. My only choice was at home.

I found my midwife who tended me with compassion, reason, and conducted all the same routine tests the OB/GYN from my first pregnancy conducted. But she also gave me so much more. She gave me the only promise she could reasonably make --- that she, her associate acting as her back up, or the student who followed me through my pregnancy as well --- would see me through to the end, whatever that end would be, unlike the OB/GYN who not only didn’t assist with my labor but failed to assist me in providing appropriate care in the months after my son was born. To this day, I am still in touch with my midwife --- though she is not currently practicing since completing her Masters in Public Health and finding a
position conducting women’s health research.

To finally conclude, and I thank you for your attention to this point, much rhetoric is given to the risk of birthing at home. But we can’t discuss that without also discussing the risks in birthing in a hospital.

Life is risk. Every day is a risk. We get to make choices about the risks we take. I chose the risk of birthing at home after my hospital birth because of trauma, because of dismissive care providers, because of pain caused by the procedures that I had in a hospital. I chose the risks of home birth because I had chosen the risks of the hospital the first time, and the second time, I couldn’t take on those same risks again. The ongoing PTSD symptoms from my first birth that persisted in my second pregnancy were enough to handle without adding on to it by being forced into a hospital birth due to a lack of options.

I am not anti-hospital birth, even after my own experience, and I am also not so pro-home birth that I believe all women can safely birth at home. But I fully 100% believe the option should be available, options where the consumer (pregnant women) can know that those providing midwifery services for home birth have met competency standards set by the Commonwealth, that data on homebirths can be collected in a more meaningful way in order for consumers to make informed decisions about the risks they decide to take in choosing to give birth in a hospital, in a birth center, in a home. Women are capable of making intelligent decisions about their own health. No birth is without risk, and the people
who should assess which risks are worth taking is the woman having the baby in conjunction with her care provider.

And lastly, since home birth is not going away, it is vital that the Commonwealth make
it safer by adopting the standards set forth in An Act Relative to Certified Professional Midwives (Bill numbers HB 2008 and SB 1081).

As it was, my choice in risk to birth at home was the right one. Should I have a third child, I’d take on those same risks again.

I thank you most kindly for your time today, and I am happy to speak with you further about my experiences.

Sincerely,

[Zizzle]"

Me on Radio Boston.

Me on the Mom Meet Mom blog about my experiences.

Don't like abortion? Don't have one. Don't like homebirth? Don't have one. But that doesn't mean that we shouldn't make both abortions and homebirth the safest possible options we can.

And safe ---- what is safe? Are you talking safety of the baby? Are you talking safety of the mother? Are you talking the longterm well being of the dyad? Are you talking the best outcome for the entire family?

That is going to be different for everyone.
posted by zizzle at 11:38 AM on February 27, 2014 [17 favorites]


Here's the bill.
posted by zizzle at 11:43 AM on February 27, 2014


People who are using @username, that's not done in here please. Just address them by their username and the message will get through, trust me.
posted by Purposeful Grimace at 11:50 AM on February 27, 2014 [2 favorites]


Another important context to the discussion is long-term outcomes. This should be studied, and there is very little data currently. As with any other life decision, mortality risk has to be weighed against long-term wellbeing.

The available data we have is that for Americans the single best thing you could do to reduce mortality risk for your baby is to move to Europe or Canada before becoming pregnant. Should that be the recommendation, lol?
posted by lastobelus at 11:52 AM on February 27, 2014


And if one side argues for home birth because of a concern of getting unnecessary pitocin or getting "pressured into" pain medication as if that is an equivalent risk to getting, for instance, the known condition of an amniotic fluid embolism at a home birth

dios, you've mentioned amniotic fluid embolism twice now as an example of a risk that home births can't deal with. Wikipedia says, "The condition is so rare (between 1 in 8000 and 1 in 80,000 deliveries, although more recent studies show 1 in 20,464 deliveries for a more precise number) that most doctors will never encounter it in their professional careers, and as a result the exact process is poorly understood."

On the other hand, many, many women are pressured into getting epidurals they don't need. This can slow down labour significantly, requiring the injection of pitocin, which can increase pain, leading to more epidural drugs. Then the baby starts to get too much of the epidural drug, slowing down the baby's heart rate, leading to an emergency C-section that was totally avoidable, and which introduces all kinds of risks of infection and massively increases healing time.
posted by Dasein at 11:53 AM on February 27, 2014 [1 favorite]


Actually, natural childbirth and homebirth are the ideological twins of anti-vax, and most women who choose homebirth are anti-vax.

They are strikingly similar in that both are anti-science to their core, but hide behind the language of science. The difference is that most skeptics are now familiar with the vaccine literature and can't be fooled while most skeptics are unfamiliar with the obstetrics literature.

The anti-vax crowd feels that it is informed. It has created an alternative world of internal legitimacy with its own experts, credentials, conferences and journals. If you speak to the average anti-vax afficianado, they will tell you that "science shows" that vaccines are dangerous, etc. Homebirth is exactly the same.

The conclusion of the MANA paper, that they have shown homebirth to be safe, is a bald faced lie and the folks at MANA know it. This dataset has existed for 5 years. In that time MANA has publicly released (and boasted about) the C-section rate, the intervention rate, the transfer rate in the homebirth group, but they have adamantly refused to release the death rates. Those death rates were recently released only as a result of public pressure. I started a petition campaign to force MANA to release the data.

It is imperative to MANA to hide the hideous death rate at homebirth. The way they chose to do that is to leave out the appropriate comparison group, the CDC Wonder database. They now say that the database is unreliable, but they have been quoting it for years in a variety of contexts including to condemn the US for its infant mortality rate. ALL research on perinatal, neonatal and infant mortality in this country is based on that database and their are a variety of studies demonstrating the accuracy of various piece of data. Deaths, birth attendant and location are highly reliable (since the CDC added birth location in 2003). The CDC Wonder database is the reference for all birth related research in the US, and for MANA to leave it out is unjustifiable. But they had to do it in order to hide the hideous death rates.

Whenever a homebirth advocates says to you that "the evidence shows," remember that anti-vax folks say that, too and really believe it, but it's not true for anti-vax and it's not true for homebirth.

Amy Tuteur
posted by DrAmy at 11:53 AM on February 27, 2014 [8 favorites]


If this is where this argument is headed, we are basically heading into anti-vax territory.

Dios, from my neutral standpoint that really is an assholish thing to say.

People have legitimate concerns about unnecessary medical procedures and pressures and you dismiss it by say 'oh you're just like the anti-vaxers'? Seriously? That is poor arguing and insulting to the people you're trying to engage with.
posted by edgeways at 11:54 AM on February 27, 2014


and most women who choose homebirth are anti-vax.

You'll have to cite that.


And people say home birth folks are arrogant?
posted by edgeways at 11:56 AM on February 27, 2014 [3 favorites]


most women who choose homebirth are anti-vax.

I would like to see a source for this statement. It is not true in my experience.
posted by KathrynT at 11:56 AM on February 27, 2014 [10 favorites]


most women who choose homebirth are anti-vax

Cite, DrAmy? About half of my friends who have had kids have done homebirth, and none of them are in the least bit anti-vax, to the point of being the sort of people who do a lot of sharing of posts on Facebook and Tumblr that openly mock anti-vax people--like, rabidly pro-vaccination types. I won't argue that there aren't some people who do this, but unless you've got a cite, I think this is grossly mischaracterizing the sort of women who care about this issue in this day and age. At best, there's a sizeable number of people who are in fact pro-vax and pro-homebirth, whether or not they are actually in the majority, and so conflating the two is not accurate.
posted by Sequence at 11:56 AM on February 27, 2014 [4 favorites]


Apparently that brain cell is going to have to be split a few ways.
posted by Sequence at 11:57 AM on February 27, 2014


DrAmy I'm the farthest thing from an anti-vaxer imaginable. I would politically support fines and/or imprisonment for failure to vaccinate one's children. You lose all legitimacy by insisting I'm cognitively the same as an anti-vaxer. Homebirth needs to be regulated. It needs to be assisted by properly trained professionals. It needs to have codified protocols to allow those professionals make good decisions in the heat of the moment. In civilized countries it is getting all those things. You are doing nothing to help it get those things in your country with your approach.
posted by lastobelus at 12:00 PM on February 27, 2014 [5 favorites]


Don't know if it matters, but my health providers have said several times, "I wish she'd just go away," when I've brought Dr.Amy up in discussion.

She is not helping anything, and that currently practicing medical providers in the area in which she lives dislike her this much should be telling about the lack of respect she currently has within the medical community. Period.

Even from those who would otherwise agree with her.

Also, I know many more people who had babies in hospitals who don't vaccinate than I do people who have birthed at home who don't.
posted by zizzle at 12:01 PM on February 27, 2014 [4 favorites]


most women who choose homebirth are anti-vax

I would dearly love to know how you conclude this.

It is imperative to MANA to hide the hideous death rate at homebirth.

I'm going to give you the benefit of the doubt that this is an American thing. This is absolutely false in Ontario, which has a well-regulated midwifery system that delivers excellent care for a fraction of the cost. Please follow this link. A study undertaken by McMaster found no increase in infant mortality in home births vs. hospital births in low-risk births - which are, of course, the only kinds of births that should be taking place at home. It also found that serious complications and medical interventions were lower in the home-birth group.
posted by Dasein at 12:01 PM on February 27, 2014 [1 favorite]


Wow, DrAmy is Mefite's own! I did not know this. Thanks for joining our conversation.
posted by ThePinkSuperhero at 12:02 PM on February 27, 2014 [2 favorites]


Thanks for joining our conversation.

Maybe?
posted by MisantropicPainforest at 12:02 PM on February 27, 2014 [2 favorites]


I'm happy to provide citations but wonder why you want to wade into the weeds rather than address my main point:

MANA is LYING about what its own study shows. They have barricaded themselves into their own websites, blogs and message boards and will not come out to engage with me or any one else who could point out their deception. They are willing to talk only to friendly journalists.

Read the MANA paper, investigate the CDC Wonder database (public and free), look at other US perinatal, neonatal and infant mortality research to confirm that it is the standard. Compare MANA's death rates to low risk white women at term in the CDC database and let me know what you find.

Another key point is that the MANA paper is not a "study," it is a non-random survey where approximately 75% of eligible homebirth midwives refused to participate and 25% the ones who did participate did not fill out the full survey. Even so, it shows homebirth as a 450% higher death rate. MANA knows it. Don't let them get away with lying about it.
posted by DrAmy at 12:04 PM on February 27, 2014 [1 favorite]


I agree, MANA's obfuscation of their own outcome data has been shameful in the extreme, and is one of many reasons why I do not trust that organization. But I really would like that cite you mention. It should be obvious by now that in the group of people you're speaking to, "homebirther" does not equal "antivaxxer."
posted by KathrynT at 12:06 PM on February 27, 2014 [1 favorite]


They are not equivalent risks, they are more risky because they are MUCH more likely to happen in a hospital than a home birth or a birth center.

I cannot understand what you are saying. You are saying that it is more risky to get pain medication than it is to get an amniotic fluid embolism (and if you don't like that one example condition, pick your maternal/fetal concern: ecclampsia that needs mag sulfate to avoid HIE, etc.)

And maybe I was unfair comparing your position to an anti-vaxxer because I haven't given you the opportunity to explain it fully. For instance, I have heard people claim that pitocin is dangerous and so home births are better to avoid it, and that argument is as silly as the anti-vax argument. Let me explain: we have been using pitocin in birthing for about about 4 decades and have a cohort of several hundred million babies who have been exposed to it, so we would have statistical certainty if there was a problem. The same thing with the vaccine-autism nonsense. When you get cohorts this large, there is no scientific doubt whether there is a cause and effect issue. So that's what I meant there. But in fairness to you, you haven't made the pitocin argument. But you hinted that there was a problem with epidurals, and the same argument applies because the epidural argument is often part and parcel with the pitocin argument. The other side is this: we have fine organizations such as ACOG which establish guidelines about what is proper and safe. People who object to practices approved by ACOG based on unestablished fears, I kind of see that as people saying the CDC can't be trusted on vaccinations. That's where my comment was coming from.

Look, I fully support hospitals--such as where we had both of our kids--who give the mother complete respect for her birth plan. No epidural, lights dimmed, music playing, doula present, etc. etc. We chose our hospital because of that. I get it. My beef isn't with theories about that stuff. My issue is with people who advocate home birth because giving birth is too risky to not do in a hospital if that is an option. Too much can go wrong that the risk calculus says you should be in a hospital. That's my issue. And I have a secondary issue with people who act like concerns over ACOG approved treatments are somehow equivalent risks to the dangers of a home birth such as the risk calculus favors home birth. That strikes me as just not credible.
posted by dios at 12:06 PM on February 27, 2014 [8 favorites]


Actually, natural childbirth and homebirth are the ideological twins of anti-vax, and most women who choose homebirth are anti-vax.

That is a hell of a hill to die on, Dr. Amy. You may well have some pertinent observations to make about morbidity and mortality rates, but trying to tar your opposition like this causes you to lose any credibility you had to make the argument.
posted by Mayor West at 12:07 PM on February 27, 2014 [8 favorites]


Well because if you don't provide cites for an extraordinary claim that claim will be dismissed and cast doubt on all subsequent claims.

There are lots of anecdotal cases of mothers giving birth at home who are decidedly not anti-vax (my mom gave birth at home to half my sibs and is not anti vax), so making such a sweeping claim better be backed by pretty rigorous evidence by your own standards.
posted by edgeways at 12:08 PM on February 27, 2014 [1 favorite]


For instance, I have heard people claim that pitocin is dangerous and so home births are better to avoid it, and that argument is as silly as the anti-vax argument.

Pitocin is dangerous because it drastically increases the C-section and epidural rate, both of which are dangerous.
posted by MisantropicPainforest at 12:12 PM on February 27, 2014 [1 favorite]


The issue with the epidural, dios, is that it can slow down or stall labor. That's not woo-woo handwaving, it was on the informed consent paperwork that I signed before I got mine in the hospital. Stalled labor increases the risk of trouble. Pitocin is an excellent medicine that has saved probably hundreds of thousands of lives and prevented zillions of c-sections -- but when overused it can cause major problems. Again, that's not hippie crystal chanting bullshit, it's supported by ACOG itself.

I am pro-epidural. I am pro-pitocin. I am pro-C-section. All of these things are major advances in obstetrical medicine, when properly used. But they are not without risk, and to act as though they are is disingenuous.
posted by KathrynT at 12:13 PM on February 27, 2014 [11 favorites]


The Editor of the leading homebirth midwifery "journal" Midwifery Today, Jan Tritten, is explicitly anti-vax as is the "journal"

The Association between Birth Place, Birth Attendant, and Early Childhood Immunizations

Steve Robison, Immunization Program, Oregon DHS, Health Services, demonstrates the link quite clearly.

But, again, that is not the focus of this discussion. The focus is, and should be, whether MANA is dishonest about the meaning of the high death rates at homebirth.
posted by DrAmy at 12:18 PM on February 27, 2014 [1 favorite]


One homebirth advocate being anti-vax is not the same as "most homebirthers" being anti-vax, and you know it. Can you link to an actual study? If you didn't want to be called out on that claim, you shouldn't have made it.
posted by KathrynT at 12:19 PM on February 27, 2014 [3 favorites]


That is not a cite, and you do not get to decide the focus of the discussion.
posted by edgeways at 12:19 PM on February 27, 2014 [14 favorites]


I think we have a situation where NEITHER side has the best credibility.

Horrible OB's, whose 'care' crosses the line to abuse for many patients, have poisoned the well just as bad as Horrible Midwives.

Again, if you're not IN LOVE with your OB, and 100% positive you're on the same page, you HAVE TO SHOP AROUND.

If your OB won't come to your home to deliver your baby, that might be a showstopper.
posted by mikelieman at 12:20 PM on February 27, 2014


Least of all on Metafilter where people will continue to call on you to back it up until you do. And if you don't, your credibility regarding just about any statement involving facts will be questioned.

You picked the wrong forum in which to preach.
posted by zizzle at 12:21 PM on February 27, 2014 [2 favorites]


I am pro-epidural. I am pro-pitocin. I am pro-C-section. All of these things are major advances in obstetrical medicine, when properly used. But they are not without risk, and to act as though they are is disingenuous.
posted by KathrynT at 2:13 PM on February 27


I agree. They are not without risk. And I never said they were not risk-free. Everything involves a risk. That's why I discussed a risk calculus.

And if you are the type who can appreciate and are risk-adverse enough to make decisions based on the minor risks of these procedures, I cannot fathom how you would assume the risk of home birth which has major risks if one of the many curveballs occurs. Between hospital and homebirth, there is no doubt which one the more risk adverse person would choose.
posted by dios at 12:23 PM on February 27, 2014 [1 favorite]


@dios You have no understanding of risk calculus at all if you can't fathom how a reduction in a minor but frequent risk could outweigh an increase in a major but very rare risk.
posted by lastobelus at 12:26 PM on February 27, 2014 [2 favorites]


@dios And I very much hope I get a chance to play poker against you some day ;)
posted by lastobelus at 12:26 PM on February 27, 2014


Between hospital and homebirth, there is no doubt which one the more risk adverse person would choose.

And does the fact that there are many risk adverse people who are properly informed and choose to have a homebirth suggest to you that maybe you're valuation of risk isn't the only-one-true-path and that maybe people value other things?

Also, are you including the possibility of dying in a car accident in your calculus? Because people have to drive to hospitals, and doing so is dangerous and could kill your whole family.
posted by MisantropicPainforest at 12:27 PM on February 27, 2014 [1 favorite]


And if you are the type who can appreciate and are risk-adverse enough to make decisions based on the minor risks of these procedures, I cannot fathom how you would assume the risk of home birth which has major risks if one of the many curveballs occurs. Between hospital and homebirth, there is no doubt which one the more risk adverse person would choose.

Because people's risk tolerances are different. Some people are more comfortable with a tiny risk of a catastrophe than with a substantial risk of a more minor threat. Those aren't two things that can be directly compared.

Besides,in my case, leaving my house once labor started involved a SUBSTANTIAL risk of having an unattended birth on the side of the freeway, which I think we can all agree is a terrible place and manner to give birth.
posted by KathrynT at 12:27 PM on February 27, 2014 [3 favorites]


This is obviously a pretty complicated issue. There are dangers to homebirths in that you don't have all the emergency medical resources available to you, but there are also certainly dangers in a hospital and we can debate whether c-sections are needed as often as they seem to happen and maybe a homebirth avoids. Everyone's welcome to figure out what levels and types of risks they're willing to put up with. Personally I think home births are too risky in the event of an emergency, but I have college educated friends that did it and I supported their choices.

The anti-vax stuff is a side issue we should probably drop, as the connection seems minor and not absolute to home birthing.
posted by mathowie at 12:28 PM on February 27, 2014 [5 favorites]


Which risk are you seeking to avoid, dios?

Or did you completely ignore my comment in that my family could not have handled another hospital birth? That stepping into a hospital not in labor led to panic attacks? What do you think would have happened had I a panic attack during labor in the hospital? Increased blood pressure on top of normal increased blood pressure during labor. What does increased blood pressure lead to?

Lots of poking and prodding that'd have led to further panic attack to further blood pressure escalation to GET THE BABY OUT NOW!

I guarantee you my STATE OF MIND was such that it'd have completely sabotaged any chance of having the kind of labor I'd have wanted by merely BEING IN THE HOSPITAL.

I didn't choose homebirth lightly. And I didn't pick a quack. My then nurse practitioner developed a huge professional respect for my midwife, and my current family medical practitioner thinks my choice to homebirth was an excellent one given the circumstances of my first birth and general experiences after.

But that was my choice.

I know someone who had an unplanned c-section after a long labor like I did with her first, but with her second, she chose to have a scheduled c-section at 39 weeks. And you know what? She lost the baby at 38 weeks. It was devastating. Absolutely devastating. So she had her third by c-section at 36 weeks.

I do not judge her decisions in the least. Her cirucmstances were completely different and for her, having a planned c-section much earlier than is typically recommended was the risk she was willing to take to have the best outcome not only for her baby, but for her own mental well being.
posted by zizzle at 12:33 PM on February 27, 2014 [1 favorite]


Yeah but at least someone's making a metric fuckton of money on these interventions.

When I was researching the pros and cons in preparation for my birth, I remember reading a surprise statistic as to why doctors/hospitals are inclined to intervene. Apparently, when something goes wrong, women who get C-sections or other procedures sue less and win lesser damages, because C-section = Something Was Done (even if the C-section was medically unnecessary and Bad Things happened anyway).
posted by rada at 12:36 PM on February 27, 2014 [1 favorite]


Apparently, when something goes wrong, women who get C-sections or other procedures both sue less and win lesser damages, because C-section = Something Was Done (even if the C-section was medically unnecessary and Bad Things happened anyway).

No-one gets (used to get) fired for buying IBM Mainframes.
posted by mikelieman at 12:38 PM on February 27, 2014


Giving birth to my first child involved generous doses of pitocin and equivalent doses of different painkillers, for very good reasons. It was absolutely necessary. But it prolonged the labour and the pain, and increased the risk for the baby (in order to prevent an even greater risk).
With that experience, I concluded I wanted to do an all natural birth the next time round if the OB would let me. She would and I did, and it was great. I trust doctors and their judgements, I am grateful for western medicine, I think anti-vaxers should be fined. But I also believe childbirth is a natural procedure which should be carefully monitored, but not "treated" in 85% of all cases. Because for many, many mothers, the so-called treatment prolongs the labour, and increases the complications. And then I haven't even begun to talk about c-sections.
posted by mumimor at 12:39 PM on February 27, 2014


That line of argument is the analogue of the anti-vax "Big Pharma pushes vaccines for profit."

Homebirth represents 1/2 1% of US births, therefore it represents 1/2 1% of lost obstetric income and no loss of GYN income. Homebirth represent 100% of the income of homebirth midwives. You tell me who has the greater economic incentive to lie about the danger of homebirth.
posted by DrAmy at 12:42 PM on February 27, 2014 [4 favorites]


By the way, did you know that MANA, the organization that represents homebirth midwives and wrote the paper, has NO safety standards of any kind? It's up to each midwife to decide for herself what's safe and what's not.
posted by DrAmy at 12:45 PM on February 27, 2014


If the problem is so small, DrAmy, why are you so obsessed with it?
posted by mumimor at 12:45 PM on February 27, 2014 [3 favorites]


I personally have never bought any line of argument on any topic that involves "doctors are doing it for the MONEY!" hysteria. I know plenty of doctors, and most of them don't know a damn thing about money as it relates to how they practice. I suppose if they wanted to chase after money, they might have gone to business school instead of medical school. Certainly would have taken less time!
posted by ThePinkSuperhero at 12:45 PM on February 27, 2014 [6 favorites]


Hey Dr. Amy, ugh, when a journal publishes something, that doesn't mean they write it.
posted by MisantropicPainforest at 12:46 PM on February 27, 2014


From improvingbirth.org and relevant here I think.

The truth is that there’s no such thing as “safe” or risk-free birth in any setting. For each of us, “safety” and “risk” are complicated calculations made within limitations of our individual circumstances and the options at hand. For mothers and families making these important decisions, statistics are helpful, but statistics only illuminate the corners of our own unique sets of certainties and uncertainties.

Polarizing arguments and digging in our heels about these issues don’t make birth safer. Insisting that one location is always safe and one location is never is ridiculous. Pretending that all women are making decisions based on a full set of good options or the same set of health circumstances is unrealistic. Making judgments about someone else’s personal circumstances is nonsensical. We can never know all of the factors that go into those complicated decisions.

posted by Otis at 12:48 PM on February 27, 2014 [4 favorites]


My woo homebirth vegan friends proudly announced on facebook the other day they are following the CDC vaccination schedule. It may have been true in the past that homebirth/natural birth advocates were vaccination weary, but that is because they have a different value system about the purpose of medicine that I completely agree with, and therefore DO disagree with doctors about a lot of things. Vaccinations are well worth the potential risks according to research we have now, in my opinion, even if you're weary of the current medical model of disease development and healing; but the agreement of the "the medical establishment" that things should be a certain is not universally the case. I disagree with current medical practice about a lot of things (and so does a lot of peer reviewed research, not that that's proof of correctness but so too does the medical establishment have blinders on accepted research conclusions and implications) so I think it's understandable many were hesitant to trust them on vaccines. I think current thought on treating many conditions is so utterly wrong about so many things and once things are established doctors I have talked to often refuse to question about the way they view human health and healing and the amount of emotional support and nurturing and more that is a very valuable part of healing, health, and wellness and that is routinely neglected in applications to systems of healing (though that is changing a lot especially as more and more research indicates that relaxation, poverty, abuse, isolation, chronic work stress, psychosocial variables, and variables like diet, exercise, activities and social interaction are an intricate part of disease development, prevention and healing.)
posted by xarnop at 12:49 PM on February 27, 2014


Thank you, Otis!
posted by zizzle at 12:50 PM on February 27, 2014


dios, I whipped together a google spreadsheet to help you improve your understanding of risk calculus. I chose the numbers completely at random without thinking about it too much and it came out with almost twofold value increase from the intervention that focuses on the low-value high-frequency risk. I <heart> my risk calculus instincts.
posted by lastobelus at 12:53 PM on February 27, 2014 [1 favorite]


I am surprised that there is so much argument against the idea that the anti-vax and home birth movements have substantial overlap. In my experience the people I know that did home births were entirely anti-vax. But I am interested in seeing the statistics, since I recognize that my anecdotes are just that (much as the people testifying the other way). I did some googling and could not find any surveys, although I will note that many of the recent news stories I found did cite the fear of vaccines (also: circumcision) as a common factor in parents choosing home births.
posted by norm at 12:54 PM on February 27, 2014 [1 favorite]


I don't really understand the Dr Amy pile-on, she did give a citation. Although she doesn't appear to have formatted the link:

https://cdc.confex.com/cdc/nic2008/techprogram/P15773.HTM

Results:
Overall 132,473 Oregon births were included in this study. While 97.9% of births were in hospitals, 82.7% had a M.D. as the attendant. The 2,200 children who were born in locations other than a hospital or freestanding birthing center were 8.8 times more likely not to be seeking or receiving immunizations than those born in hospitals. Those with a direct-entry or non-certified midwife in attendance were 7.4 and 8.8 times more likely to not be shot seeking as those with an M.D. However the 19,600 children born with a certified nurse midwife in attendance at a hospital were 1.1 times more likely to be shot seeking than those with an M.D. Similar results were obtained for UTD rates for these groups.

Conclusions:
A birth outside of a hospital is a strong factor both for not seeking immunizations, and for not completing series for those that do seek immunizations.

posted by hobo gitano de queretaro at 12:55 PM on February 27, 2014 [14 favorites]


In my experience the people I know that did home births were entirely anti-vax.

All the certified nurse midwives that I know, and I know A LOT of them, are pro-vax.

If someone is going to make a prima facie silly claim like Dr. Amy did, they are going to have to present some evidence for it, especially if it contradicts most peoples lived experience.
posted by MisantropicPainforest at 12:57 PM on February 27, 2014 [1 favorite]


Here is the fact: Home births are going to continue to happen. Period. Whether you I and the catholic priest down the road likes it or not. Just like underage sex, just like drug use, abortions and so on, driving without seat-belts (or hell just driving at all).

So, we have choices. We can work to make systems as safe as possible for those that chose this route, and there will always be some, we can advocate for education, proper training and backup, we can do all we can to support those who make this decision and drive down rates of 'incidents'.

Or, hell we can demonize them and push to remove any safeguards and drive it further underground and make it less and less safe, and some can go on the lecture circuit as a one trick pony barely able to talk about anything else.
posted by edgeways at 12:57 PM on February 27, 2014 [8 favorites]


"More homebirthers don't vax than hospital birthers" is not the same as "homebirthers are overwhelmingly anti vax."
posted by KathrynT at 1:03 PM on February 27, 2014 [12 favorites]


lastobelus: the problem with your analysis is your comparative weight given to the risks. That is a topic upon which we are unlikely to agree. Needless to say, I assign virtually inconsequential value to the risks for many of the concerns voiced here and an incalculable value to the risk of death or serious impairment. You seemed to think they were in the same ballpark, and now we are back to my earlier comment.
posted by dios at 1:04 PM on February 27, 2014 [3 favorites]


By the way, did you know that MANA, the organization that represents homebirth midwives and wrote the paper, has NO safety standards of any kind? It's up to each midwife to decide for herself what's safe and what's not.

Given that, does it not occur to you that your role as a public health advocate might better be served by um, advocating safety standards, decision protocols, regulatory guidelines, etc. as has already been happening in many countries (see Sweden, Canada, Switzerland, etc.) rather than poo-flinging?
posted by lastobelus at 1:04 PM on February 27, 2014 [4 favorites]


Regardless, anti-vax is a derail and luckily we can ignore it for this discussion.
posted by agregoli at 1:04 PM on February 27, 2014 [4 favorites]


That is a topic upon which we are unlikely to agree. Needless to say, I assign virtually inconsequential value to the risks for many of the concerns voiced here and an incalculable value to the risk of death or serious impairment.

Yeah, and to each her own. Birth is an intensely personal thing and if someone doesn't share you're particular subjective risk aversion/assessment, that doesn't mean that any one particular viewpoint is stupid or myopic or selfish.
posted by MisantropicPainforest at 1:08 PM on February 27, 2014


dios you seem to assign inconsequential value to the risk of interventions when the risk of those interventions is that they lead to a risk of other interventions that have a mortality risk. Which is a bit of head scratcher for me. I don't get how that "calculus" transpires in a cerebral cortex. I certainly enjoyed the fact that it did happen in other cerebral cortexes when I used to play poker recreationally (positive EV of 12.7 BB/100hands over 120Khands -- but at $20 NL so not particularly significant)
posted by lastobelus at 1:08 PM on February 27, 2014


Which makes me ask explicitly something I alluded to.

Why aren't most OB's making housecalls?
posted by mikelieman at 1:13 PM on February 27, 2014


Malpractice insurance doesn't allow them to.
posted by zizzle at 1:15 PM on February 27, 2014


I DO advocate for safety standards. MANA OPPOSES them. That's one of the key points.

MANA lied when they claimed that their data shows that homebirth is safe, but they were honest in acknowledging that homebirth for breech and VBAC have very high mortality rates. Nonetheless, as we speak, homebirth midwives in Arizona are advocating for increased scope of practice to include breech and VBAC.

With all due respect, most of the people arguing here in favor of homebirth appear to know very, very little about MANA, about homebirth death rates, about the obstetric literature and about MANAs efforts to gut any safety standards that anyone proposes. MANA recently "strengthened" the requirement for the CPM to include a high school diploma. Does that sound to you like a group committed to safety?
posted by DrAmy at 1:16 PM on February 27, 2014 [2 favorites]


Malpractice insurance doesn't allow them to.

Well, then Insurance Reform should be the focus of this discussion, shouldn't it?

The PATIENT is the priority. Everything else is secondary. If the insurer is preventing effective care, the solution is simple.
posted by mikelieman at 1:17 PM on February 27, 2014


So...what about the bill in the Commonwealth of MA right now?

That would set forth safety standards and form a licensing body with recourse to prevent bad midwives from practicing and would require an OB to be on the board?

There are serious efforts under way to make safety standards for homebirths --- but you do in fact oppose those, too.
posted by zizzle at 1:18 PM on February 27, 2014


Does that sound to you like a group committed to safety?

It sounds like an opportunity to form a group which promotes your agenda here, rather than just getting all pissed off at the other guys. Provide a better alternative rather than just criticizing.
posted by mikelieman at 1:19 PM on February 27, 2014 [1 favorite]


I'm curious if anyone has a link to the full text of the Robison article? I'm curious about numbers vs percentages.
posted by edgeways at 1:19 PM on February 27, 2014


Do the Laws of New York make this pearl-clutching irrelevant? ( at least in NY? )

http://www.op.nysed.gov/prof/midwife/article140.htm
posted by mikelieman at 1:21 PM on February 27, 2014


Does anybody get the sense that this is a DrAmy vs MANA situation, and that the real truth lies somewhere in between and far more nuanced than either's position?
posted by entropone at 1:22 PM on February 27, 2014 [4 favorites]


I'm curious if anyone has a link to the full text of the Robison article? I'm curious about numbers vs percentages.

It's linked in this comment.
posted by bluefly at 1:24 PM on February 27, 2014


dios, given the level of rhetoric you've used, I would appreciate if you would disclose how often you drive your children somewhere instead of using public transit.

From age 6 months throughout the entire period for which you are responsible for their care, driving is the number one mortality risk for your children -- by an order of magnitude. I want to know how you personally weight that against convenience and time in a risk calculus where mortality supposedly outweighs everything?
posted by lastobelus at 1:25 PM on February 27, 2014 [4 favorites]


wait, it's not, I had it the article open on another tab and searched for the wrong link.
posted by bluefly at 1:25 PM on February 27, 2014


bluefly, thanks I was questioning my -powers of read-itude
posted by edgeways at 1:26 PM on February 27, 2014


"That would set forth safety standards and form a licensing body with recourse to prevent bad midwives from practicing"

What safety standards would those be? Does it set up a board to review midwifery cases? What disciplinary action is available when midwives violate safety standards?

The fact is that licensing has nothing to do with safety and everything to do with money. Insurance companies will not reimburse midwives who don't have licenses, hence the drive for licensing. There are quite a few states that already have licensing and there is no oversight and either no review of midwifery malpractice or review by friends of the midwife under investigation.
posted by DrAmy at 1:28 PM on February 27, 2014


I feel like we humans spend a lot of time trying to really wring any chance of Bad Things happening out of our lives, which is a decent plan, but then we also like to pretend that when Bad Things do happen, it's always avoidable and someone is always at fault. This causes a lot of problems.
posted by selfnoise at 1:29 PM on February 27, 2014 [1 favorite]


YES!

It'd be just like the medical board. It'd be determining licensing with licensing exams and hours of practice. It would reprimand midwives who engaged in inappropriate practices.

IT WOULD DO ALL THE THINGS ALL THE OTHER REGULATING BODIES OF ANYTHING DO!

If hair stylists have to be licensed, why the hell wouldn't you want homebirth midwives licensed and accountable to a board?
posted by zizzle at 1:29 PM on February 27, 2014 [3 favorites]


"Do the Laws of New York make this pearl-clutching irrelevant? ( at least in NY? )"

No, NY doesn't allow homebirth midwives and we are talking about homebirth midwives?
posted by DrAmy at 1:30 PM on February 27, 2014


"It'd be just like the medical board. It'd be determining licensing with licensing exams and hours of practice. It would reprimand midwives who engaged in inappropriate practices."

Please quote the relevant language.
posted by DrAmy at 1:30 PM on February 27, 2014 [1 favorite]


Homebirth is not illegal in NY, so that it's not allowed is misleading.
posted by zizzle at 1:31 PM on February 27, 2014


Homebirth midwives are a second class of midwives. The NY laws allow only certified NURSE midwives, just like every other state allows.
posted by DrAmy at 1:33 PM on February 27, 2014 [1 favorite]


Does anybody get the sense that this is a DrAmy vs MANA situation, and that the real truth lies somewhere in between and far more nuanced than either's position?

Well, no. I get the sense that the truth is closer to DrAmy's position. That she is clearly combative and super focused on this doesn't affect whether or not her position is correct. Note, for example, how many people jumped on her for the vax thing and continued to claim she had not backed up her comment even after she clearly had done so. That was mostly a result of her style being abrasive rather than any lack of factual accuracy on her part.
posted by Justinian at 1:38 PM on February 27, 2014 [6 favorites]



Section 264. The committee shall:

(1) examine applicants and issue licenses to those applicants it finds qualified;

(2) adopt regulations establishing licensing and licensing renewal requirements;

(3) issue permits to apprentice midwives;

(4) investigate complaints against persons licensed under this chapter;

(5) hold hearings and order the disciplinary sanction of a person who violates this chapter or a regulation of the committee;

(6) approve education and apprentice training that meet the requirements of this chapter and of the committee and deny, revoke, or suspend approval of such programs for failure to meet the requirements;

(7) adopt standards for approved midwifery education and training;

(8) adopt professional continuing education requirements for licensed midwives;

(9) develop practice standards for licensed midwives that shall include, but not be limited to:

i. adoption of ethical standards for licensed midwives and apprentice midwives;

ii. maintenance of records of care, including client charts;

iii. participation in peer review; and

iv. development of standardized informed consent, reporting and written emergency transport plan forms.



Further down:

The training required under this section shall include training in either hospitals, alternative birth settings or both. The Department of Public Health shall assist the committee in facilitating access to hospital training for approved midwifery programs.


Section 271. (a) The committee may, after a hearing pursuant to chapter 30A, revoke, suspend, or cancel the license of a midwife, or reprimand or censure a midwife if it finds upon proof satisfactory to the committee that such midwife:

(1) fraudulently procured licensure as a midwife;

(2) violated any provision of law relating to the practice of medicine or midwifery, or any rule or regulation adopted thereunder ;

(3) acted with gross misconduct in the practice of midwifery or of practicing midwifery fraudulently, or beyond its authorized scope, or with gross incompetence, or with gross negligence on a particular occasion or negligence on repeated occasions;

(4) practiced midwifery while the ability to practice is impaired by alcohol, drugs, physical disability or mental instability;

(5) was habitually drunk or being or having been addicted to, dependent on, or a habitual user of narcotics, barbiturates, amphetamines, hallucinogens, or other drugs having similar effects;

(6) knowingly permitted, aided or abetted an unlicensed person to perform activities requiring a license for purposes of fraud, deception or personal gain;

(7) has been convicted of a criminal offense which reasonably calls into question the ability to practice midwifery;

(8) violated any rule or regulation of the committee;

(9) acted in a manner which is professionally unethical according to ethical standards of the profession of midwifery; or

(10) violated any provision of sections 260 to 278.

(b) No person filing a complaint or reporting information pursuant to this section or assisting the committee or board at its request in any manner in discharging its duties and functions shall be liable in any cause of action arising out of receiving such information or assistance, providing the person making the complaint or reporting or providing such information or assistance does so in good faith and without malice.

Section 275. A midwife qualified by examination under the provisions of section 268 may obtain and administer prophylactic ophthalmic medication, anti-hemorrhagic medications, vitamin K, Rho immune globulin, intravenous fluids, oxygen for fetal distress and infant resuscitation, and local anesthetic and may administer such other drugs or medications as prescribed by a physician or certified nurse-midwife. A pharmacist who dispenses such drugs to a licensed midwife shall not be liable for any adverse reactions caused by any method of use by the midwife.


THIS COMMITTEE IS TO BE OVERSEEN BY THE MEDICAL BOARD!

THE MEDICAL BOARD FOR THE COMMONWEALTH OF MASSACHUSETTS THAT ACCREDITED YOUR OWN INSTITUTION OF EDUCATION! THAT SAW YOU FIT ENOUGH TO HOLD A LICENSE TO PRACTICE MEDICINE!

If you don't trust your medical colleagues to do a decent job overseeing this committee, then you really don't have a leg to stand on with any of your arguments.
posted by zizzle at 1:40 PM on February 27, 2014 [6 favorites]


Uh, no she didn't. She never backed up her claim that most people who elect to have homebirths were anti-vax. That's bullshit and you fell for it. All of those comments are here, we can read them.
posted by MisantropicPainforest at 1:41 PM on February 27, 2014 [2 favorites]


That was mostly a result of her style being abrasive rather than any lack of factual accuracy on her part.

Which is why I was asking if anyone had the text for the study. The study kinda cited said in the conclusion that homebirths where statistically more likely to not vax, not that the majority didn't vax (let alone the vast majority). Perhaps the text says differently, but the summery provided sure didn't. Again, if the text is avail I'd like to see it.
posted by edgeways at 1:45 PM on February 27, 2014


(and yeah, the obligatory one study/one state/10 years ago)
posted by edgeways at 1:45 PM on February 27, 2014


Who is on the committee?

Oregon has a Board of Direct Entry Midwifery. The Head is Melissa Cheyney, a MANA executive. There are multiple complaints of malpractice that have been unaddressed for years. Cheyney refused to submit Oregon's MANA states to the state.

Oregon went out and hired Judith Rooks, CPM, MPH to analyze the data collected on every Oregon homebirth in 2012. Rooks testified before the Oregon State Legislature. She found that the death rate for PLANNED homebirth with LICENSED midwives in 2012 as 800% HIGHER than comparable risk homebirth.

Rooks is a long time advocate for homebirth. Here's what she said to the legislature:

"Many women have been told that OOH births are as safe or safer than births in hospitals…

But out-of-hospital births are not as safe as births in hospitals in Oregon, where many of them are attended by birth attendants who have not completed an educational curriculum designed to provide all the knowledge, skills and judgment needed by midwives who practice in any setting."

https://olis.leg.state.or.us/liz/2013R1/Downloads/CommitteeMeetingDocument/8585

Here's what Rooks said in an interview with a mother who lost her own baby at out of hospital birth:

"To my great disappointment, many young women who want to become midwives seem to think it is too much bother, time or money to complete an actual midwifery curriculum and think it is enough to just apprentice themselves to someone for a minimal number of births, study to pass a few tests, and become a CPM that way."
posted by DrAmy at 1:48 PM on February 27, 2014


Really? This statistician is using p values and assumed normal distributions to test the significance of something that is so rare (13 out of 16950!) that three or four different observations would decide whether something is 'statistically significant'.

Bluefly already pointed this out, but you can absolutely derive a legitimate p-value in situations where two groups differ on the incidence of a rare event, and it in no way involves using a normal distribution. (Fisher's exact test, for instance.)
posted by en forme de poire at 1:48 PM on February 27, 2014 [2 favorites]


The Fisher test is for small N not low base rates.
posted by MisantropicPainforest at 1:50 PM on February 27, 2014


Read the damn bill yourself.

But the fact remains, the committee has to report to the medical board. It is under the medical board's jurisdiction, to use an only partially appropriate word.

Do you trust the medical board of the Commonwealth of Massachusetts to do its job?

If not, then you don't trust any medical provider of any kind.
posted by zizzle at 1:51 PM on February 27, 2014


I do not trust homebirth midwives because they are grossly uneducated, grossly undertrained and represented by an organization that has no safety standards and lies about its own death rates.

You have provided not evidence to contradict any of these facts.

CPMs are a second, inferior class of midwife, not recognized by any other industrialized country. They don't qualify for licensure in the Netherlands, the UK, Canada, Australia or anywhere else.

If no other country will license such unqualified amateurs, why should Massachusetts or any other state do so?
posted by DrAmy at 1:54 PM on February 27, 2014


"To my great disappointment, many young women who want to become midwives seem to think it is too much bother, time or money to complete an actual midwifery curriculum and think it is enough to just apprentice themselves to someone for a minimal number of births, study to pass a few tests, and become a CPM that way."

Is the objection to home births, or to home births attended by improperly qualified midwives? Because there's no necessary correlation between them. See, again: Ontario.
posted by Dasein at 1:54 PM on February 27, 2014 [1 favorite]


See also: Washington state.
posted by zizzle at 1:55 PM on February 27, 2014


The board would be made up of an OB, CNMS, and CPMS.
posted by zizzle at 1:56 PM on February 27, 2014


This whole discussion is about homebirth in the US, not any other country. No one, least of all me, has been talking about certified nurse midwives in the US. We're talking about homebirth midwives (CPMs).
posted by DrAmy at 1:56 PM on February 27, 2014 [1 favorite]


Because you have to start somewhere to get somewhere else.

To get better standards you have to start with what you can.

Licensing is a first step. That's it. And it's a huge step to improving outcomes in general. Over time competency will go up because the standards will change. Once upon a time doctors weren't licensed, either.
posted by zizzle at 1:57 PM on February 27, 2014 [1 favorite]


Canada used to recognize the CPM but abolished it because CPMs lack the education and training they deem necessary.

If no other country in the industrialized world has a second, inferior class of midwife, why should the US?
posted by DrAmy at 1:58 PM on February 27, 2014


Neither were dentists. Or psychologists.

CNMs weren't licensed until the 80s in Massachusetts and couldn't get insurance reimbursement until the 90s.

What did you think of CNMs when you were practicing in the 80s and 90s?
posted by zizzle at 1:58 PM on February 27, 2014 [1 favorite]


OBs thought CNMs were an inferior class to OBs.

ACOG was adamantly opposed to them.
posted by zizzle at 1:59 PM on February 27, 2014


Eventually maybe we'll be able to have only "one class" able to provide in and out of hospitals.

That'd be what the longterm outcome should be.
posted by zizzle at 2:00 PM on February 27, 2014


When was ACOG adamantly opposed to them? I started my medical training 30 years ago, and I always worked with them. Ultimately I covered in a practice that had more than 20 CNMs. They were highly educated, highly trained and had excellent clinical judgment.

CNMs currently perform approximately 11% of vaginal deliveries and are well integrated into the medical system.

There is no need for lay "birth junkies" who give themselves a fake credential that is accepted by no other country that promotes homebirth.
posted by DrAmy at 2:02 PM on February 27, 2014 [2 favorites]


The Fisher test is for small N not low base rates.

You can also use the Fisher test when the expected frequencies are too low to use a chi-squared test. Either way it doesn't use a fucking normal distribution.
posted by en forme de poire at 2:03 PM on February 27, 2014


This whole discussion is about homebirth in the US, not any other country.

So are you conceding that home birth in appropriately regulated jurisdictions is safe? This seems like a crucial point. Are home births inherently dangerous, even for low-risk pregnancies, or does the lack of adequate training, regulatory oversight and integration with local hospitals mean that, in America, home births are unnecessarily dangerous?
posted by Dasein at 2:03 PM on February 27, 2014 [1 favorite]


"Eventually maybe we'll be able to have only "one class" able to provide in and out of hospitals."

We already have it. They are called certified nurse midwives. Some attend homebirths, but most do not because they think it is too dangerous.
posted by DrAmy at 2:03 PM on February 27, 2014 [2 favorites]


But it's not going away.

So do we make homebirth safer with the standards you say you want?

Or do we let it go on unregulated being as unsafe as you claim it to be?

Most CNMs don't attend homebirth because the nursing board does not let them.

What does it say that most of the CNMs at Mt. Auburn had homebirths?

What does it say that the CNM who was part of my care during my first pregnancy had a homebirth herself halfway through my pregnancy? And that she worked with an OB?

Clearly they don't mind CPMs attending them..
posted by zizzle at 2:05 PM on February 27, 2014


zizzle, got a cite for that? That's now second-hand anecdote.
posted by purpleclover at 2:07 PM on February 27, 2014


Uh, no she didn't. She never backed up her claim that most people who elect to have homebirths were anti-vax. That's bullshit and you fell for it. All of those comments are here, we can read them.

Her cite showed that people who choose homebirth are 8.8x as likely to either skip vaccinations or not complete them as those who did not. Whether that's "most people" depends on the rate in the population as a whole, obviously. Without access to the absolute rather than relative numbers we can't say one way or another what they are. Certainly I don't think it's out of line to say there is a correlation between the positions, though.
posted by Justinian at 2:11 PM on February 27, 2014 [1 favorite]


If no other country will license such unqualified amateurs, why should Massachusetts or any other state do so?

Maybe because people without health insurance can't afford them big fancy hopspitals, expensive drugs and special drug giving doctors in addition to the baby delivering doctor and all them nurses....

And that's if NOTHING GOES HORRIBLY WRONG.

The reason people NEED options is because there's two kinds of people. Wealthy, who can afford all this, and the rest of us, who maybe can't.

Again, if the OB made a housecall, 'these amateurs' wouldn't have a market.
posted by mikelieman at 2:13 PM on February 27, 2014 [1 favorite]


Saying there's a correlation between the positions is drastically different than saying most homebirthers are anti-vax. That is why people jumped all over her, because she spouted bullshit that everyone knew was bullshit.

Without access to the absolute rather than relative numbers we can't say one way or another what they are.


She has NO evidence for her position, and maked up a wildly implausible claim.
posted by MisantropicPainforest at 2:14 PM on February 27, 2014


Er, what? She has good evidence; the linked cite. As I said, I do not have access to the hard numbers or I would look at them myself. But if, as the study concludes, home birth people are 8.8x as likely to not get their kids vaccinated, the rate of non-vaccination in the general population has to be less than like 6-7% for "most" to be incorrect. Or you could fall back on the argument that not getting your kid vaccinated isn't the same as being anti-vaccination, of course, but that's a bit weak.
posted by Justinian at 2:17 PM on February 27, 2014 [1 favorite]


But if, as the study concludes, home birth people are 8.8x as likely to not get their kids vaccinated, the rate of non-vaccination in the general population has to be less than like 6-7% for "most" to be incorrect.

And actual evidence in support of the claim that most homebirthers are anti-vax would show that 'most' is a reasonable, not a possible inference from the data.

Or you could fall back on the argument that not getting your kid vaccinated isn't the same as being anti-vaccination, of course, but that's a bit weak.

Not really, since not having access to a hospital and not having access to vaccinations are positively correlated, especially in an area like Oregon that has areas of rural poverty.

Moreover, this was one state a decade ago.
posted by MisantropicPainforest at 2:23 PM on February 27, 2014


OK, so now I read both the Journal of Midwifery & Woman's Health article and the blogpost on DrAmy's blog (both linked in TFA).

First of all, DrAmy: you do yourself a disservice by mixing up the analysis made by dr. Orosz and your personal, unqualified opinion. (Unqualified in the sense that you do not back it up with data, not that you are not personally qualified).

The article in the JMWH is in every way a normal statistics-based healthcare article. The data is accessible and the conclusions are valid. After following the debate here, I agree with you, DrAmy, that allowing second-rate midwives to practice is a serious threat to women's health. However, the survey demonstrates that in spite of the very valid questions one could raise about the quality of education of midwives, and in spite of some very questionable practices, planned home births were largely successful, with only a slightly higher mortality rate than home births. Now, every unnecessary loss of a child is a horror and a scandal. But as you indirectly point out in your commentary, most of the problematic practices in the survey could be eliminated by better training and oversight with the midwives.

In your comments, you rightly focus on the breech deliveries. How can they even have begun to perform those in private homes?? And why would the mothers agree to them? That is plain crazy. An accomplished midwife will know at the latest at the beginning of labour if a child is in the breech position, and should immediately bring the mother to the hospital. In real life, she'll most probably have known days ahead, and thus has even less excuses.
But this is hardly an argument for eliminating home births. It is an argument for regulation and education. And your argument is weakened when you randomly add deaths to the number in the survey.

Regarding VBACs, I think zizzle has given a very strong argument in this thread for why it should be possible for women to deliver safely - either at home or at dedicated clinics - without hospital interference. And again, this requires well educated and regulated midwives, not turf-fights.
posted by mumimor at 2:28 PM on February 27, 2014 [7 favorites]


This whole discussion is about homebirth in the US, not any other country. No one, least of all me, has been talking about certified nurse midwives in the US. We're talking about homebirth midwives (CPMs).

Well, perhaps we have a point of agreement then. My own research led me to support my wife's (very informed) decision to have a home birth. The same research would have seen me adamantly opposing a decision to give birth in the US, home or otherwise.
posted by lastobelus at 2:30 PM on February 27, 2014 [1 favorite]


Breech births should not be done at home.

Believe it or not, I am incredibly moderate on home birth. I want it regulated so it can be as safe as it can be

People made the same arguments about abortion.

Rights to choose don't stop in just deciding to or not to continue with a pregnancy. Arguably, Amy and I agree that we want to protect women. But my take on it us home birth here is to stay. It's going to happen no matter what. It can't be stopped.

I think regulation is a path to better care. Amy thinks home birth should be eradicated from the planet and should never happen. But that's not realistic. Her idealism is stepping on her own feet.

We saw what happened when abortion was legalized and then providers appropriately regulated. It got better for women's health and for public health.

I believe the same will happen with appropriately regulated home birth midwives.
posted by zizzle at 2:49 PM on February 27, 2014


But MANA places no restrictions on breech birth or any other complication. We can't afford to license providers who have no safety standards of any kind.

As for the insurance argument, every pregnant woman in Massachusetts has insurance coverage.
posted by DrAmy at 2:54 PM on February 27, 2014


Placenta previa & particularly vasa previa births should also not happen at home. If a midwife tells you otherwise, RUN! And don't skip your ultrasound, it's the only way of finding out about vasa previa before its too late.
posted by lastobelus at 2:56 PM on February 27, 2014


dios: by the way, the numbers in my spreadsheet are not intended to align in any meaningful way with numbers in this debate, but are intended only to demonstrate how it is possible for an intervention that reduces a low-cost high-frequency risk while increasing a high-cost low-frequency risk to be a better value than an intervention that increases the low-cost high-frequency risk while reducing the high-cost low-frequency one.
posted by lastobelus at 3:07 PM on February 27, 2014


Perhaps talk about non MANA options and paths for the folks who want home births, and how to make that safer through proactive stratigies? You seem to be MANA obsessed?
posted by edgeways at 3:11 PM on February 27, 2014 [1 favorite]


Almost all homebirths in the US are attended by non-nurse midwives, and MANA represents them, licensed or not. MANA is the leading force in licensing non-nurse midwives and promoting them. Most importantly for the purposes of this thread, MANA collected and published the data we are discussing.
posted by DrAmy at 3:14 PM on February 27, 2014


Almost all homebirths in the US are attended by non-nurse midwives,

Do you see the root-cause of the issue at hand clearly?
posted by mikelieman at 3:26 PM on February 27, 2014


Yes, other health care providers have safety standards.
posted by DrAmy at 3:29 PM on February 27, 2014


If you want a group gone, you need to provide a better alternative (and it's not the hospital), not preach that everybody who had a nice, happy, successful home birth is wrong. We've tried this before in a hundred different areas. It didn't work for: abortion, alcohol, marijuana, etc. it will not work here. Make it illegal, and you just criminalize honest, decent citizens.

If I go swimming in New England, my odds of getting eaten by a shark go up probably a million-fold compared to not swimming, but they're still minuscule and anybody who tells me I shouldn't swim can get bent. Instead, why not train the lifeguards to recognize sharks?
posted by Dr.Enormous at 3:31 PM on February 27, 2014 [3 favorites]


The issue of whether MANA are making homebirth policy unsafe is a different issue than whether homebirth is innately unsafe no matter how practiced or regulated. They are two different issues. It sound like MANA is indeed a harmful entity. That does not prove home birth if properly regulated would be innately more dangerous hospital birth. (That MAY be true but we don't have statistics on what the results would be if home birth were properly regulated if indeed we have accurate statistics at present.)

Get rid of MANA, and let's make good safety regulations for home birth. Why should it be assumed MANA has to be in charge of safety regulations?
posted by xarnop at 3:32 PM on February 27, 2014 [1 favorite]


Exactly. The Canadians seem to have done a very good job ensuring safety at homebirth.
posted by DrAmy at 3:33 PM on February 27, 2014


Then why do you oppose creating safety standards? Oh right..."I don't like these people." That's not an argument; it's how my 5 year-old behaves.
posted by Dr.Enormous at 3:34 PM on February 27, 2014 [3 favorites]


Yes, other health care providers have safety standards.

So -- although I believe there is probably insufficient data to prove this -- perhaps a study showing that home births are less safe than hospital births is actually showing results because of the lack of minimum required training and standards for midwives, and the concern should be about increasing those, not about getting rid of home midwifery altogther. "Home birth isn't safe" is going to turn off a lot of people who would otherwise agree that midwives should be appropriately educated, licensed and insured, but should be allowed to attend births at a woman's house.
posted by jeather at 3:35 PM on February 27, 2014


Here is the deeply heartbreaking account by Josh Jones (co-founder of Dreamhost) about the birth and death of his son Wren in his home. Seems like a pretty typical case of what exists in the delta between hospital birth and home birth. I had only read that article because I'm a Dreamhost customer who, in his words, "remember me as the guy who used to write the newsletters and most of blog posts around here", which I had always found amusing and wondered what had happened to him. Ugh.
posted by robla at 9:13 PM on February 27, 2014 [1 favorite]


While that is undeniably a heartbreaking story, it also illustrates the failure of people other than the midwife. He admits himself that the OBs who noted the presence of GBS in his wife's urine earlier on "forgot we were planning a home birth." How is that possible, given a healthy patient-provider relationship? I'm 16 weeks along, and you can bet I would have discussed my preferred birth location and arrangements at nearly every opportunity. And secondly, if he clearly believes that CPMs are so terribly inferior, why did he and his wife let one deliver their baby? In all of the literature about having a midwife attend a birth, did he and his wife never encounter some explanation of the difference?

I'm very, VERY sorry that they lost their son. However, it didn't happen simply because one of their birth professionals lacked a few initials after her name.
posted by Madamina at 10:36 PM on February 27, 2014


It is a very sad story, and GBS is one area where I disagree strongly with the laissez-faire attitude espoused by many in the home-birth community. We got the test, having agreed beforehand that we would act on a positive result (it is risk management 101 that you should NOT get the test, or any medical test, if you're not going to do the intervention if the test is positive).

However this repeated quote: And again, why add any extra chance that your baby would die? makes no sense. We don't apply that to the rest of our lives, why would we apply it to giving birth? Every time we strap a kid into a carseat we are deciding the convenience and speed of driving is worth the nearly an order of magnitude greater risk of their dying as opposed to using public transit or walking (if either are available options). And every time we let them play we increase their risk of mortality over not letting them play. But if we didn't let them play they wouldn't think much of us now, or ever. Bearing a certain amount of added risk for a more positive experience is a valid decision, especially when there is some evidence that stressful birthing can have a long-term impact on both mother and child.
posted by lastobelus at 12:04 AM on February 28, 2014


This is pure anecdote. But our baby was born with an Apgar score of zero (i.e. no life signs) and needed emergency resuscitation. So my advice is: hospital. Things can start to go wrong astonishingly quickly: one minute they're all apparently bored and the next it's a mad scramble for the operating theatre. A hospital just has way more resources if things get complicated.
posted by TheophileEscargot at 1:13 AM on February 28, 2014


Actually, natural childbirth and homebirth are the ideological twins of anti-vax, and most women who choose homebirth are anti-vax.

Disproven by the existence of the Netherlands.
posted by MartinWisse at 2:04 AM on February 28, 2014 [2 favorites]


A hospital just has way more resources if things get complicated

Conversely, a hospital has way more incentive and resources to intervene and harm the mother and child. There are tradeoffs. People can evaluate their options and choose accordingly.
posted by MisantropicPainforest at 6:01 AM on February 28, 2014 [1 favorite]


And doulas are great (disclaimer: I am one) but many women cannot afford them.

I agree, but a home birth is 10x the cost of the doula. I would add further that for people with dodgy insurance (which is most of us in the United States) a doula will pay for themselves in many cases by helping the frenzied patients to consider options that don't include as many interventions.

But mostly, I wish folks on both sides of this issue could put aside their differences and work together to make birth better for all women, no matter where they want to do it. Period! No skepticism required.

I agree entirely. I just shared my poor experience with home birthing but ultimately we need better support and resources all around. I tend to think birthing centers with access to hospitals are an excellent middle ground.
posted by dgran at 6:04 AM on February 28, 2014 [1 favorite]


I agree, but a home birth is 10x the cost of the doula.

I think one thing common in this thread is that we are assuming that women who elect to have homebirths are educated urban/suburbanites with the internet and lots of options and information, and the education to process that information. Which is just not true in the US. In poor rural communities, homebirths are the norm, because that's how things have been done and thats how they are still done. And hospitals are far away.
posted by MisantropicPainforest at 6:20 AM on February 28, 2014 [3 favorites]


we are assuming that women who elect to have homebirths are educated urban/suburbanites

I totally missed this and appreciate you setting me straight here, because I was only seeing this through the lens of my experience. Thanks.
posted by dgran at 6:34 AM on February 28, 2014 [1 favorite]


OK, so here goes. This is also purely anecdotal, but I thought it might be interesting.

We live in Switzerland. The next hospital is a 15min walk. For a home birth there are usually two midwives present. If you're interested in their level of education, I'm sure there's info on the web.

Our first child was born in a hospital; she was six weeks premature. She was not only premature, but she also managed to wrap the umbilical cord around her neck and rip it off during birth, so she had an Apgar of 0, she had to be reanimated and needed infusions and medication and whatnots. We were lucky that a really experienced specialist was still in the hospital; if that women hadn't been around, the kid would have probably died.

So the hospital clearly saved her life. And yet, there were so many interventions that seemed unnecessary and even endangered the child, there was so little emotional support, it was such a horrible experience even if you take the medical emergency out of the equation, that we decided never to have a hospital birth if it could be avoided.

The other five children were born at home.

Two of the five children born at home had no "special circumstances".

But one was in a wrong position ("Hintere Hinterhauptslage" in German). In a hospital, that would have guaranteed a caesarean section, or at the very least a "vacuum extraction" (the English words I'm learning here are fabulous...).

And two have Down Syndrome with heart defects. Both weren't detected before birth even though we did the usual ultrasound tests in the hospital and even a maternal blood test in the case of the second kid. A birth in the hospital would have meant caesarean section (if they detected the heart defects during birth) and tons of medical intervention right after birth.

Needless to say, the births at home all went well. We delivered those babies ourselves. The midwives stayed in the background and only coached us when we needed it.

Yes, I know, there are a million things that could have gone wrong. But they didn't.

You might say we were just completely irresponsible, maybe even crazy, and clearly just lucky that nothing catastrophic happened. I say we prepared ourselves and took a calculated risk in order to avoid another horrible experience in the hospital.

We were experienced with child birth. We knew how it works and what you have to do. We had extremely competent midwives with lots of experience in home births. We knew we could reach the hospital if it was necessary. And we had the self-confidence that is necessary if you want to take life in your own hands instead of chickening out and delegating all the decisions to other people, like is common in today's "zero risk" society (nope, I'm not nearly as luddite as that sounds).

Birth is always dangerous. Life is dangerous. There's no way around it. You deal with it as best you can. This is how we did it. I'm not saying it's the only way to have a wonderful and safe birth experience. But home birth did work well for us.
posted by Tanjit at 7:08 AM on February 28, 2014 [5 favorites]


Birth centers are really great.

But the two in MA do not aUTllow VBACs. If either of them had, I might have chosen that over homebirth. It's madness that hospital policy dictating VBACS cannot occur in their attached birth center is what leads women in my position to homebirth.

I was also GBS+ when I had my homebirth. My midwives stayed for hours after. My husband watched for signs in our baby. Our regular care provider checked her out the next day. One of the midwives came everyday for three or four days after the birth.

The Wren Jones story is heartbreaking, but it's also very clear that baby was struggling in the posted videos. First sign of distress like that should have sent them to the hospital, which was our plan as well.

My midwife was clear --- a single doubt, bring her in. Don't hesitate. Just do.
posted by zizzle at 7:28 AM on February 28, 2014


No, NY doesn't allow homebirth midwives and we are talking about homebirth midwives?

I had a homebirth a month and a day ago in New York State with a certified nurse midwife.

Incidentally, I just got a call from their office today that there was an abnormality on the newborn screening test and we need to retest this week. For some reason I didn't get the voice mails until 9 pm tonight. Cue freaked out, panicked googling and weeping. But then I texted my midwife and asked if she could clarify and talk me down and she did. At 10 o'clock on a Friday night. With a regular OB, it would have been panic attacks and crying all weekend.

My midwives were careful to tell me at our first meeting with them that even though I might see myself as "having a homebirth," they look at the situation differently--I'm receiving the midwifery model of care. That meant that, if everything remained low risk, I might be able to give birth at home. But more importantly, I'd receive care that was centered around myself and my family. Our appointments were over an hour each; they encouraged us to get as much testing as possible and carefully discussed the results of each test and ultrasound with us. And our birth was a really, really positive experience, despite the fact that I pushed for a very long time (longer than most hospitals in the area would allow). The baby was monitored throughout. Her apgars, when she finally showed up (sunny side up!) were a 9 and a 10. She's healthy. I'm healthy (well, I had some hemorrhoids and one tiny stitch). Sure, I got to sleep in my bed on the first night. But I also got to establish my relationship with my daughter on tremendously positive grounds. I had struggled with depression and anxiety over the course of my pregnancy, but have had a really, really great postpartum experience. I strongly suspect that the positive birth experience has something to do with that.

But beyond that, what's really floored me about my midwives has been their postpartum care. They visited us four times in the course of two weeks, sent a lactation consultant when my daughter was having trouble latching, gave us physical exams, advised us on how to dress a newborn given our drafty apartment. They'd visit, and it would feel like having a treasured family member visit, but then I'd check their online system and realize that they were actually watching us carefully all along. Many of their reports reflect that they're watching me for postpartum depression (again, of which I've been blissfully free). There were also recommendations that my "very supportive" spouse eat more regular meals in the first days after birth, that kind of thing.

I don't know. I'm about as far from anti-vax as you can get, but I'm pretty much completely gaga about the midwifery model now. A big part of my motivation to explore homebirth is my anxiety disorder and propensity toward panic attacks with people who intimidate me. That might sound trivial, but I really worried that it would be a problem during my birth. But the whole experience has been radically different than what I expected. It wasn't about the birth, or only the birth, but about the comprehensive health and well-being of my entire family.
posted by PhoBWanKenobi at 7:40 PM on February 28, 2014 [6 favorites]


As long as we're throwing out anecdotes (and your midwife does sounds wonderful), I should mention that my OB responded to my texts/emails around the clock, and also checked in regularly to see if I needed help with lactation, how I was feeling, etc. She handled my pre-eclempsia with grace and tact, and has a wonderful successful VBAC rate. The practice also offered amazing new mom's meetups and child care classes.

I think we are ill-served by setting up a false dichotomy between horrible OBs and amazing midwives. There are good and bad with both (a friend had such a horrible experience with her midwife that she never wants to give birth again). Rather than arguing about subjective opinions about risk tolerance, I wish we spent more time educating parents-to-be about what good care looks like, and how to advocate for it.
posted by snickerdoodle at 8:37 AM on March 1, 2014 [4 favorites]


I agree, and I don't at all think that the existence of good midwives eliminates the possibility of, or even the need for, good OBs. The ideal system is one where they work cooperatively for the good of the patient (Peggy Vincent's book Babycatcher discusses a close-to-ideal system, which existed in the US in the eighties and nineties; the British series The Midwives shows what a modern cooperative midwifery system, which allows for low risk homebirths, might look like in practice).

But I gotta say, the discussion from DrAmy here, which treats qualified nurse midwives who attend home births as illusory as the tooth fairy, is damned frustrating for those of us with experiences to the contrary.

Also, did else anyone notice this?

natural childbirth and homebirth are the ideological twins of anti-vax, and most women who choose homebirth are anti-vax.

It's one thing to lump together homebirth and anti-vax; its WRONG, but I understand the impulse. But to put every woman who wants to experience non-medicated, physiological childbirth in the same box as anti-vaxxers is just RIDICULOUS. That's not to demonize those who want a medicated birth--its a deeply personal choice, and not even always a choice--but from the perspective of both personal and public risk assessment it makes no fucking sense.
posted by PhoBWanKenobi at 10:18 AM on March 1, 2014 [3 favorites]


its WRONG, but I understand the impulse

It's not that wrong, as Dr Amy has shown with her citation. They share things in common.
posted by stoneandstar at 1:24 PM on March 1, 2014


"most women who choose homebirth are anti-vax." is what she said. It's an assertion of fact and of math. It's testable and it's falsifiable. It is not supported with the citation she included which supports more of a "More homebirthers don't vax than hospital birthers" conclusion as KathrynT said above. Maybe it was an accidental statement, I can see how to many people those two statements might seem more similar than they actually are, but the fact that they share things does not have anything to do with the truth value of what she said. I think it's a red herring to this conversation certainly except insofar as the main link was about how "when you do the math, it turns out..." and it seems like people are getting a bit held up on just how to do the math, about anything.
posted by jessamyn at 1:34 PM on March 1, 2014 [2 favorites]


"sharing things in common" is not the same as "ideological twins" and I'd really like to know how she's supporting the idea that natural childbirth--which can take place in a hospital, with an OB-GYN--is the ideological twin of anti-vax.
posted by PhoBWanKenobi at 2:39 PM on March 1, 2014 [1 favorite]


jessamyn: I think it's somewhat more accurate to say that without access to the hard numbers we can't say with absolute certainty one way or another where it is supported by the citation she included. But that what we cansee suggets it is supportable. I would also assume she has seen the numbers herself, being someone in a position to have access to such things, but of course we can't know that with certainty either.

Why it's supportable: If the data shows that homebirthers are 8.8x as likely to be non-vaxxers than hospital birthers (and that study says so) we can see if "most" is an accurate statement by looking at the fraction of non-vaxxers in the general population. The latest numbers suggest that in Oregon the number of kids not being vaccinated has risen to between 6-7% of the population.

If homebirthers are 8.8x as likely to not be vaccinated and the rate among everyone is around 6.5% that puts the rate of vaccination among homebirthers at marginally under 50%, which makes "most" as a potentially accurate (barely) claim. Although I think a lot of people generally wouldn't use "most" to describe 50.1% or similar numbers it's still technically correct.
posted by Justinian at 2:53 PM on March 1, 2014


I think it's a red herring to this conversation certainly except insofar as the main link was about how "when you do the math, it turns out..." and it seems like people are getting a bit held up on just how to do the math, about anything.

Though yeah, I agree with this. I just think that the factionalization and broad-strokes demonization of "homebirthers" and "homebirth midwives" or even advocates of "natural childbirth" is a big part of the problem here and largely makes the conversation less productive at actually helping women make better choices in birth. The more I think about it, the more I come to believe that it's actually impossible to have this conversation without discussing "subjective opinions about risk tolerance." If the "independent statistician" picked by Amy Tuteur's numbers are correct, we're still talking about an exceedingly small relative risk. For some, that relative risk is worth it in exchange for other benefits of homebirth (for example, a decreased risk of c-section). For some it isn't. That's okay, but what I'd really like to know is how we can improve conditions for both mothers and their children in the US--and that means not just improving neonatal and maternal death rates either in hospitals or at home but also improving conditions in both arenas to avoid problems like postpartum depression and birth-related PTSD.
posted by PhoBWanKenobi at 3:05 PM on March 1, 2014 [2 favorites]


Late to the thread, but I've been following this debate closely.

What Dr. Amy is crusading against is untrained, under-regulated lay midwives against a backdrop of increasing numbers of home births and a radical fringe very much connected to anti-vaxxers and radical mistrust of the medical profession. This very different from what goes on in birth centers or with well-trained and regulated certified nurse midwives attending home births, like the ones PhoB used.

The MANA stats seem to bear out that there's a fringe of midwives engaged in shockingly reckless behavior, like breech homebirths, and that in general there's a higher risk for all homebirths. There are other studies showing sharp increased risks for bad outcomes short of death, too -- a 10x increased risk of an Apgar of 0 and consequent brain damage.

The anecdotes Dr. Amy collects about homebirths resulting in death and injury serve to illustrate the fact that there are untrained midwives out their guided more by ideology than medical practice. You really just have to read these stories to fully internalize just how far out there some of these lay midwives are.

As homebirth grows into the mainstream, Dr. Amy is absolutely correct to sound the warning that homebirth midwives may increase risk of bad outcomes. Parents deserve to be fully informed of this, at the least. Personally, I think that lay midwives should be banned and only actual nurses be allowed to do home births. Because at the end of the day, 100% of parents will prefer a c-section to a dead or brain damaged baby.
posted by yarly at 6:00 PM on March 1, 2014 [1 favorite]


What's a "homebirth midwife" though? If she's talking purely about CPMs, she should say so. My CNM attends homebirths and reports birth stats to MANA. I'd definitely consider her a "homebirth midwife" and I'd imagine she'd consider herself one, as well. This is not the way midwives talk about themselves or the way that "homebirthers" talk about them. Anecdotes about death and injury can be collected about hospital births, too. Ina May Gaskin shares vivid anecdotes on her website about maternal deaths, for example. But that's not data, anymore than anecdotes about infant death are data. Hell, is this story about a whole family contracting antibiotic resistant staph from a birth center birth pool reason to call for an outlawing of birth centers? Of course not.

Because at the end of the day, 100% of parents will prefer a c-section to a dead or brain damaged baby.

Tell that to those who lost a spouse to c-section complications like infection or hemorrhage? I don't know that it's always clean cut as it's made out to be; not all C-sections are medically indicated, not all of them are done to avoid dead or brain damaged babies, and they carry a higher risk than vaginal birth to both the baby and the mother. Which is not to say that there aren't absolutely necessary and lifesaving c-sections. Because there absolutely, undoubtedly are. It can be a lifesaving and very necessary procedure. But it's not without it's own risk--just like homebirth.

Personally, I think that lay midwives should be banned and only actual nurses be allowed to do home births.

The rise of modern CPMs has a lot to do with the insurance and litigation situation in the US. It's not that CNMs who want to perform homebirths don't exist--it's that in many areas, they can't. Which means that less educated individuals will take there place because--just like abortion--there will likely always be women who wish to give birth at home. Get rid of both lay and nurse midwives and you're going to have women who (shudder) give birth unassisted.
posted by PhoBWanKenobi at 6:25 PM on March 1, 2014


The vast majority of homebirths are by non-CNMs. That's who Dr. Amy is referring to when she talks about homebirth midwives. Not your midwives. And the fact that CNMs can't get insurance coverage or licensing approval to attend homebirths does not exactly argue in favor of the safety of home birth!

Yes, there are too many c-sections, but I think the evidence pretty clearly shows that the risks of bad outcomes are higher for homebirths. I don't think maternal mortality is any higher in the hospital either.

The point of anecdote here is not to be swayed by emotional stories, but to understand on a narrative level why homebirths are dangerous. If you read the accounts Dr Amy collects, you'll see that there's a group of truly fringe, truly scary practitioners, holding themselves out as medical professionals.

And I think the idea that there's a hardcore subset of women who will give birth at home isn't that relevant. There's definitely an increasing cultural trend towards homebirth as a choice relatively "normal" people make (Ricki Lake and all that.) It's all not about hippies in the woods anymore.
posted by yarly at 6:51 PM on March 1, 2014


The vast majority of homebirths are by non-CNMs. That's who Dr. Amy is referring to when she talks about homebirth midwives. Not your midwives.

~20% of the midwives who reported on the MANA study are CNMs. Sure, a majority of the midwives on the report are CPMs, but 1/5 of participating midwives is hardly an insubstantial number. CNMs do attend homebirths in certain states; they are homebirth midwives.

And the fact that CNMs can't get insurance coverage or licensing approval to attend homebirths does not exactly argue in favor of the safety of home birth!

This has as much to do with the deep pockets of hospitals as it does with safety. If you want to understand on a narrative level, so to speak, the intracacies of insuring homebirth CNMs, the Peggy Vincent memoir I recommended upthread is a good place to start. She lost her insurance after both she and an Ob-Gyn colleague were implicated in a case of infant injury. He continued practicing, as doctors usually do after such things happen. She lost her insurance and had to close her practice. Same baby, same injury.

Yes, there are too many c-sections, but I think the evidence pretty clearly shows that the risks of bad outcomes are higher for homebirths.

Does it? Maternal mortality rate for c-sections is two to four times higher than for vaginal birth. The relative risk of infant death is higher for homebirth, but as many people have said here, we're talking about a comparison of a very very small sample size held up against a larger sample size (and one that looks a bit cherry-picked to me--the number plucked from the CDC database is a population of all white women, while the MANA stats include 8% non-white women--I'm not sure that they're really comparable) and an absolute risk that is still very low.

I don't really know the difference between being "swayed by emotional stories" and "understanding on a narrative level" stories of "fringe, truly scary practictioners." I have friends who had absolutely traumatic hospital births--some of whom settled out of court with the hospitals following injury to their children and signed NDAs, so you won't find their stories online. But again, these are just anecdotes. And their vividness (and the lack of equivalent hospital stories when the data shows that deaths do happen to both babies and mothers in hospitals) doesn't mean these experiences are any more representative of the overall care.
posted by PhoBWanKenobi at 7:34 PM on March 1, 2014


80% is the vast majority in my book, especially given that the shadier midwives are probably less likely to report.

As far as narratives go -- I honestly have no interest in telling anyone how they should give birth. But telling women that home birth is just as safe as hospital birth if the evidence shows otherwise is unethical. It's fine to say "the risk is low," and they should have left it at that. "No concomitant increase in adverse events" crosses the line.
posted by snickerdoodle at 8:59 PM on March 1, 2014 [1 favorite]


The thing is, because of the way the data was whittled down from the CDC database, I'm not entirely sure that the evidence actually does show otherwise--again, we're comparing a population that's not precisely equivalent, supported by analysis by a statistician who was selected by someone who has based her career on mud-slinging and ad hominem attacks (like her pretty vicious claim that Ina May Gaskin has "blood on her hands" for suffering the loss of her own child, born two months premature, in the 70s). There are just a lot of factors here that make me raise an eyebrow, not in the least, again, the fact that the absolute risk is very very low even if the relative risk sounds high.

Frankly, I doubt anyone on either side here is going to do any convincing. I do wish we could work together on improving the face of American birth rather than speculating who is guilty of being like an anti-vaxxer or whatever. But oh well. I have a fussy and hale newborn to tend to in the meantime.
posted by PhoBWanKenobi at 9:21 PM on March 1, 2014 [1 favorite]


Do you have any evidence that the data selection was skewed, or that the analysis is wrong? She states clearly what she removed (low birth weight and women who did not receive prenatal care) and who she didn't (teenagers, overweight women, poor women). In her comments, she also says that the only way the numbers come out as MANA claims is if you don't remove the low birth weight babies from only the CDC data, and she removed them from both data sets in order to focus on low risk cases. The numbers for high risk are far worse. Regarding maternal death, there was only one on the MANA sample, which makes the death rate similar too the hospital one but too small to be statistically valid.

In addition, her findings are consistent with the Cornell study that came out roughly the same time.

I also agree that we should move to a blended model with trained, licensed, and insured midwives integrated into the medical establishment. However, if MANA thinks that their outcomes are the same or better, what's their motivation to do so? Rather than responding to these numbers by saying "we need to do better and here's how," we are seeing attacks on the researchers and methodology.

Again, I'm not saying that the data shows that home birth is too dangerous. That's a subjective claim in this case. But it clearly shows that it's riskier, and denying that fact does nothing to help parents seeking to make an informed decision.
posted by snickerdoodle at 3:50 AM on March 2, 2014 [2 favorites]


I think looking at why women choose homebirth should be looked at in improving both homebirth and hospital outcomes.

And by outcomes, I don't mean only a living mother and baby, though should be the minimum standard. The minimum standard.

But for the hospital setting, that is it. That is all they do. Living mother? Living baby? So long.

The minimum standard in the hospital needs to be raised. It should be:

Living mother and baby.

If that has been accomplished, then healthy mother and baby ( which is not the same as living) should be the next goal

If that has been accomplished, then the next goal should be happy mother and baby

Too many hospitals stop at the first or second. It is atrocious abd part of what leads women who have had experiences like mine down a dangerous path of PPD of being told what matters is they have a healthy baby to the exclusion of their own experiences, that their trauma even when expertly handled by the practitioner for the minimum standard of living baby, living mother is of no consequence. What they experienced doesn't matter because, hey, there's a baby at the end of the rainbow.

That is wrong.

Right or wrong, many homebirth midwives fill this gap. The nature of their care in taking on so few clients compared to OBs and CNMs means they get to know their clients very well and are better able to support them in all areas of health in the post partum period. Plus, they see their clients way more in that six week period, too.

That many women who are choosing homebirth fall in the same demographic as women who are most likely to choose abortion -- married or partnered with at least one child already --- suggests hospitals need to take a look at where they are failing new mothers.

Some number of women will always choose homebirth. But some, like me, may have chosen differently if we left the hospital the first time feeling alive instead of wishing we were dead.
posted by zizzle at 6:38 AM on March 2, 2014 [3 favorites]


I've been saying this over and over, that since the OB professional orgs are in denial about their dismal patient care 'standards', maybe the PRACTICE OF OBs is what needs reform instead to recenter them on the humanist aspects of patient care.

But since that's not going to happen, again the best way to deal with it in my opinion is to just lay it all out there for your OB, and if there's the SLIGHTEST question of her being judgemental or not 100% on your side, FIND ANOTHER OB WHO YOU CAN WORK WITH.

You're hiring these people to provider personal services. It's time for OB's to learn to treat their pts AT LEAST AS WELL as their hairdresser treats them.
posted by mikelieman at 8:18 AM on March 2, 2014


Disney(TM) Birthing Centers -- Where Magic Happens(TM)

Safety, Courtesy, Show, and Efficiency. In that order of priority.

Start teaching that in Continuing Ed for a change, you won't wonder why people would rather accept a greater risk than hire you.
posted by mikelieman at 8:20 AM on March 2, 2014


Maybe we need to rebrand the whole thing: "Don't hire asshole OBs. You deserve better." And that homebirth midwives are simply "The Market Reaction" to the situation offering up what people want. To be treated like people.
posted by mikelieman at 8:23 AM on March 2, 2014


Do you have any evidence that the data selection was skewed, or that the analysis is wrong?

Sure. Orosz says that "The WHO estimates the intrapartum stillbirth rate across North America as 0.3 per thousand." That statistic was selected from low risk white women. But the MANA population is only 92% white, and includes higher risk women (who clearly had poor outcomes--true midwifery model care wouldn't allow these women to birth at home, for good reason). You might argue that the populations are generally similar, but that 8% might have a significant statistical difference--women of color have poorer outcomes in childbirth generally.

We're not quite comparing apples to apples is the problem here.

Also, not to harp on this too much, but 19% of homebirths in 2009 were attended by CNMs. Again, CNMs are homebirth midwives one fifth of the time. It seems strange that people might argue that 8% or 19% are insignificant populations when they're also arguing that the very very small elevated relative risk--decimal points!--in this data is significant.

Maybe we need to rebrand the whole thing: "Don't hire asshole OBs. You deserve better." And that homebirth midwives are simply "The Market Reaction" to the situation offering up what people want. To be treated like people.

"Midwife" means "with women." The entire approach is different--I don't think it's necessarily a market reaction, because midwives have existed for a long time in many places. But I do think women want to be treated like people. And I don't think the idea that they deserve to be is a radical belief.
posted by PhoBWanKenobi at 8:29 AM on March 2, 2014


And also, of course, many women don't have much of a choice in who they hire. Even if their insurance situation lets them select a practice for themselves, the nature of hospital rotations and work schedules means that you might get that asshole OB when you're giving birth anyway.
posted by PhoBWanKenobi at 8:30 AM on March 2, 2014


Whoops, you know what? I just realized I plucked out the wrong statistic; what I was arguing is the case for this blog post from DrAmy but not necessarily the statistician's breakdown--I see that she's arguing from WHO statistics, not the CDC. My bad.
posted by PhoBWanKenobi at 8:47 AM on March 2, 2014


Does it? Maternal mortality rate for c-sections is two to four times higher than for vaginal birth. The relative risk of infant death is higher for homebirth, but as many people have said here, we're talking about a comparison of a very very small sample size held up against a larger sample size (and one that looks a bit cherry-picked to me--the number plucked from the CDC database is a population of all white women, while the MANA stats include 8% non-white women--I'm not sure that they're really comparable) and an absolute risk that is still very low.

Look, there are numerous studies showing that homebirth is more risky to babies. Not just death, but also a 10x greater risk of an Apgar of 10. This is not just Dr. Amy blog posts, but other studies published in medical journals. There are no studies showing that hospital births are linked to more maternal mortality than homebirths. To the extent the data is biased, it is biased *in favor* of homebirth, since a substantial proportion of homebirth mothers transfer to hospitals ... not to mention the fact that the MANA data was self-reported an self-selected. Furthermore, there is evidence that there is a fringe of radical homebirth practitioners doing things like breech and twin and pre-eclampsia homebirths, espousing rhetoric that encourages women to forgo medical care they need. Finally, the majority of homebirth midwives are NOT CNMs and have no meaningful regulation by the state or professional organizations.

Certainly OB practices could and should improve. But as it stands, the policy case for increased regulation (or prohibition) of homebirths by lay midwives has been exceedingly well made.
posted by yarly at 9:00 AM on March 2, 2014 [1 favorite]




At, the same time, yarly, Mothers have better outcomes at home.

I can't link...on phonr...but there's a 2009 study that found this as the result when compared to a hospital cohort group.
posted by zizzle at 12:01 PM on March 2, 2014


And better outcomes isn't only referring to life and death but things like trauma and interventions like episiotomy.
posted by zizzle at 12:12 PM on March 2, 2014


But as it stands, the policy case for increased regulation (or prohibition) of homebirths by lay midwives has been exceedingly well made.

Again, prohibit homebirths (or make it functionally impossible), and you'll just see the rise of less qualified practitioners as well as unassisted births. And as you've said, it's a practice gaining acceptance in the mainstream, not just among "hippies in the woods." That alone is good reason to make it safer and encourage cooperative relationships between OBs and homebirth attendants. States that outlaw homebirths still have planned homebirths; you just end up with practitioners who are more afraid to transfer women in the face of prosecution. That's not a good situation for mothers or their babies.

Again, I don't think this conversation is changing any minds at this point. Those of us who chose homebirth are fairly unilaterally aware of the increased relative risk (but again, very low absolute risk) to their children. My feeling is that, if you trust women to make birthing and reproductive choices that are best for themselves and their families you have to accept that not all women are going to weigh risk the same way that you would. Many women would prefer, for example, the increased risk of c-section and attendant risks, or infection and attendant risks, to the low risk of c-section but relatively higher risk of poor neonatal outcome. It's not the choice that I made, but I would defend a woman's right to make that choice for herself. She knows best for herself and her family, just as I know what's best for me.
posted by PhoBWanKenobi at 1:43 PM on March 2, 2014 [2 favorites]


Outlawing home births by lay midwives is not the same thing as outlawing home births of all kinds. More akin to outlawing back alley abortionists than to outlawing abortion.

The CPM is a joke credential if anything goes wrong, and if nothing goes wrong, anyone can attend a birth. So why is the CPM a necessary credential that must be legitimized by the state? So people can justify charging thousands of dollars? So they can ride the coattails of the CNM?
posted by the young rope-rider at 2:27 PM on March 2, 2014 [1 favorite]


I don't necessarily agree that the CPM is a joke credential (you can find the credentialing requirements on the NARM website, and it includes participation in a midwifery apprenticeship or attendance at a midwifery school--2 years clinical experience and 2-5 years as an apprentice, according to their guidebook), though I feel more comfortable with the credentialing behind a CNM. If the call is for more stringent licensing and credentialing for CPMs, or expansion of insurance so that CNMs cab practice in more places, sure. But if the call is to disallow CPMs to practice while CNMs also aren't able to practice in most areas, then you're essentially outlawing homebirths with trained professionals, even if it's not the stated intention.
posted by PhoBWanKenobi at 2:59 PM on March 2, 2014


The problem right now is CNMS are nurses first and midwives second. That is even how their title is phrased. As such, their professional nursing licensing board prevents them from practicing in homes in many places. CNMS in MA are forbidden expressly from delivering babies in a home setting. I'm sure many would if they could.

I know of numerous CNMS who were attended at home by CPMs, including the one who worked with the OB who oversaw my first pregnancy and delivery. Clearly she didn't find the CPM's credentials questionable.

If your objection is the quality of the credential, then CNMS need to be allowed to attend homebirths without losing hospital privileges and the ability to carry malpractice insurance.

OR individual states develop licensing bodies for the CPM credential that raises the CPM credential closer to a CNMs.

Neither is wrong, and in MA the latter is going to be much easier to accomplish than the former.

Places where CNMS are allowed to deliver at home are probably in better footing in many ways. But tons of places do not have that option.
posted by zizzle at 3:24 PM on March 2, 2014 [1 favorite]


Sure. Orosz says that "The WHO estimates the intrapartum stillbirth rate across North America as 0.3 per thousand." That statistic was selected from low risk white women

But her analysis was based on actual mortality rates from CDC data, not estimates. That's why the question of which data to exclude comes up at all.

The author of the Cornell study regarding risk did not call for banning home births. Instead, he says that:
"We recognize that parents may expect that giving birth at home will enhance the experience. In the end, we need to be frank with parents about the risks. At the same time, physicians, midwives and other practitioners need to do everything we can to contribute to the compassionate care of mothers-to-be and their infants,"
This is a far more honest and respectful approach that than trying to just hand wave the risk away, which is what I see MANA doing.

Hopefully they will follow up and isolate the variables that lead to higher mortality (my guess is if you did a state by state analysis, you'll find that states with more stringent licensing requirements will have far better outcomes) so we can make homebirth safer for everyone.
posted by snickerdoodle at 3:24 PM on March 2, 2014 [1 favorite]


The CPM is a joke credential if anything goes wrong,

The CPM credential differs state-to-state. One thing I'd definitely like to see is a standardization of what a "CPM" means; at Bastyr University in Seattle, it's either a 5-year MS/BS combined program or a 3-year post-bac program, and it is solid. The CPMs who attended my birth were Bastyr-trained. I'd like to see that level of training be the standard to achieve the CPM credential, not these 16-month distance-learning courses that result in dangerous, untrained providers.
posted by KathrynT at 4:05 PM on March 2, 2014 [2 favorites]


The CPM credential differs state-to-state.

From what I've gathered the CPM is the credential given by NARM, which has different possible routes (a midwifery school, an apprenticeship, or "self-study", all with a test and a clinical component at the end), while an LM (licensed midwife) is the usual state certification. But it's all pretty confusing, particularly when many of the terms (CPM/DEM/LM/lay midwife) are used interchangeably or inconsistently.
posted by PhoBWanKenobi at 4:19 PM on March 2, 2014


To that end, my midwife trained at Materindad la Luz, which is accredited by the TX health department.

My CPM delivered babies in Haiti after the earthquake in places somewhat cut off from medical care, due to the seriousness of injuries doctors were busy overseeing. She advocated for some of her clients to receive csections because they needed them and the culture there is too few as compared to too many.

She turned away numerous clients for high risk issue and begged thrm to just go with the hospital instead of interviewing other CPMS because she knew some would be irresponsible and take them on.

She viewed her job as very practical. She is perhaps the least woo person in the world.
posted by zizzle at 4:22 PM on March 2, 2014


Suggesting that we need to understand why 1/2% of women choose homebirth so we can change their minds is like suggesting we need to understand why parents think vaccines cause autism. Both have nothing to do with the medical system and everything to do with the gullibility of the people who hold those beliefs.

You can search high and low, but you'll find that the only people who think homebirth with a CPM is safe is homebirth advocates themselves. There is not a single paper published by an independent researcher that shows homebirth to be safe.
posted by DrAmy at 5:34 PM on March 2, 2014


There may not be according to you, but I also just don't care. I've made my reasons for my family and for my situation clear. My nurse practitioner and family doctor had a collaborative relationship with my midwife. My daughter is thriving. My midwife now works in women's health research after earning a Masters in Public Health from BU.
I'd make the same decision I made over and over again.

If you wanted to change people's minds, you should have gone with Nate Silver to review the stats of that study, Especially if you wanted to reach the masses in any meaningful way. I'd be curious, actually, about what he'd have to say. But then, he never just looks at one study or one poll, either.

So, whatever you say, whatever you could possibly tell me doesn't make a damn bit of difference to me. You're not saving lives, you know.

I'm not particularly gullible, either. I knew I could die at home. I also knew I was far more likely to die in a car accident either on the way to or home from the hospital. I still chose what I chose. I still would again.
posted by zizzle at 6:19 PM on March 2, 2014 [1 favorite]


If we're just a bunch of fringe wackadoodles, then clearly you don't need to dedicate your career to dissuading us from making this choice. After all, we're irrational and can't be convinced, just like anti-vaxxers. But unlike anti-vaxxers, we're not a public health menace. The only people we're hurting are ourselves and our babies.

If you're concerned with actually improving the lives of women and their children, then it stands to reason you'd also want to understand what it is about hospital birth that leads them to make these choices, and it also stands to reason that you'd want to actually improve the outcomes of homebirths through better collaborative relationships with hospitals and better credentialing. Instead, this feels like it's a lot of divisiveness that actually doesn't improve the situation for anyone.
posted by PhoBWanKenobi at 6:28 PM on March 2, 2014 [1 favorite]


Oh man, PhoB, I'm such a wackadoodle my csection birthed formula fed kid with autism is fully vaccinated.

As is my homebirthed, breastfed neurortypical kid.

I win Early Parenting Bingo!
posted by zizzle at 6:33 PM on March 2, 2014


I'm part of a group for women who have lost babies at homebirth or have babies who were disabled by homebirth. It's not a joke even though it might seem like it to you.
posted by DrAmy at 7:22 PM on March 2, 2014


And I know several women whose babies were disabled during hospital births. Their stories are heartbreaking, but anecdotes, no matter how vivid, aren't data.
posted by PhoBWanKenobi at 7:36 PM on March 2, 2014


Now we have data. That's the whole point of this post.
posted by Pruitt-Igoe at 8:08 PM on March 2, 2014


The difference is that the risk is much higher at homebirth. It is rare for a woman with no medical problems or pregnancy complications to lose a baby in childbirth. It's not rare at home. Approximately 4,000,000 women give birth in the US each year. Only about 25,000 give birth at home with a CPM. I know off the top of my head of 50 women whose babies have been injured or died at homebirth. Do you know 10,000 term babies who were died or injured in hospital birth, because that would be the comparable number? Do you even know 1,000? How about 100? I doubt that you do, because term hospital deaths are rare.

See what I mean about the dramatically increased risk of death at homebirth?
posted by DrAmy at 8:15 PM on March 2, 2014


We have data. That's the whole point of this post.

Right, but the absolute risk of anything bad happening to low-risk women in either hospitals or at home remains very low. The vast majority of women who birth at home will not have dead babies; the same is true, of course, for the vast majority of women who birth in the hospital, despite the fact that babies do sometimes die in hospitals. Which is why vivid stories of bad outcomes--like this absolutely terrible story of a baby being crushed by forceps--isn't an argument for outlawing hospital births.

I don't think it was right of MANA to advertise that there was "no" increased risk. They could have just reiterated what they say in the study: "Collectively, our findings are consistent with the body of literature that shows that for healthy, low-risk women, a planned home birth attended by a midwife can result in positive outcomes and benefits for both mother and newborn."
posted by PhoBWanKenobi at 8:40 PM on March 2, 2014


"We recognize that parents may expect that giving birth at home will enhance the experience. In the end, we need to be frank with parents about the risks. At the same time, physicians, midwives and other practitioners need to do everything we can to contribute to the compassionate care of mothers-to-be and their infants,"
They have it backwards.

It's not that giving birth at home will "enhance the experience". It's that MANY PEOPLE HATE THE HOSPITAL EXPERIENCE FOR GOOD REASON.

Dr. Amy, you want to fix this? If you're an OB, attend people in their homes. If there are things preventing that, then FIX THOSE ISSUES.

But the problem isn't the risks of homebirth. It's that the OB's don't give a shit about the real issue. THEIR PRACTICE HAS MADE THEM HATED BY MANY PEOPLE. And they'd rather take the increased risks than deal with the doctor and nurses bullshit.
posted by mikelieman at 3:21 AM on March 3, 2014


She can't.

She's not an OB any more. She doesn't hold a license to practice and hasn't practiced for nearly 20 years. I could be wrong on the number of years, but I'm not that far off.
posted by zizzle at 4:09 AM on March 3, 2014


The fact remains, in everything from medical studies to drug trials to dentistry, there is "an acceptable risk" for side effects. Sometimes the side effects include death and some times the side effects are slightly increased in some populations.

I could argue that people should have to stay in a hospital for 24 hours after having their wisdom teeth extracted.

Death is always a possible side effect of life. Accepting treatment outside of emergency medicine with no DNR paperwork is always at the discretion of the patient.

I think people who smoke are making a really dumb decision. But it's their dumb decision to make. Why can't you accept that some people will make what you consider a dumb decision even in light of whatever evidence you have? It's still their choice to make.
posted by zizzle at 4:18 AM on March 3, 2014


They have it backwards.

How is it backwards? He's saying that hospitals aren't doing a good job, and that is one of the key reasons people are turning to homebirths, and that the medical establishment needs to do better. From the article: "It's critical for caregivers and hospitals to create a welcoming and comfortable birthing environment, often a primary motivation for planned homebirth."

I have a ton of sympathy for home birth; I was born at home, and of my mom's 5 births, only the last was done in the hospital, and she described it as by for the worse. But I talked to a ton of doulas and midwives during my research, and finally went with an OB because it was far harder to separate the woo from the legitimate than I thought it would be. I actually had to switch doulas because mine advised me to put garlic in my vagina to reduce the chances that I would again test GBS+ in my follow up exam. There's a huge difference between "no intervention" vs. "minimum intervention" as far as birth goes, and I found the former distressingly full of woo. Luckily, I found OBs who were on the latter end, and I hope that the increase in home birth prompts more doctors to rethink their methodology.

That said, I do believe that home birth can be acceptably safe. However, the way to get there is not to pretend the added risk isn't there, but rather to figure out how to minimize that risk. Those breech numbers are horrifying, and if I were running any of the well-respected midwife organizations, that would be the first thing I'd target.
posted by snickerdoodle at 7:32 AM on March 3, 2014 [1 favorite]


When getting OB's out of the hospital and into peoples' home is parenthetical, they're doing it wrong. You want to make homebirth 'safer'? Make it commonplace for OBs to show up and support midwives.
posted by mikelieman at 7:52 AM on March 3, 2014



Now we have data. That's the whole point of this post.
posted by Pruitt-Igoe at 11:08 PM on March 2 [+] [!]


Did you actually read the post and the statisticians supposed debunking of the research? Its shoddy at best.
posted by MisantropicPainforest at 8:13 AM on March 3, 2014


Frankly, after my experiences with my midwives, I'm not sure I'd ever seek out OB care unless I was high risk. I had so many experiences with paternalistic, condescending OBs and doctors even when I was just coming in for well-woman care and birth control. Not unilaterally bad--I do believe that there are good OBs, who offer woman-centered care, as in the case of snickerdoodle's OB. I just haven't had much luck finding them. Whereas I was instantly comfortable both with the approach and the personalities of mine. Maybe it was simply serendipity and not the result of the particular model of care. I don't know.

Mostly, I really do wish our system was closer to that in the UK or Canada, where well-educated midwives with good practice relationships with OBs were available to all, whether birthing at home or in the hospital.
posted by PhoBWanKenobi at 8:43 AM on March 3, 2014


Did you actually read the post and the statisticians supposed debunking of the research? Its shoddy at best.

Please show me where an actual statistician or social scientist debunks the research. And it's only the latest data point; every academic study has shown homebirth to be riskier in the US.
posted by snickerdoodle at 9:34 AM on March 3, 2014


Please show me where an actual statistician or social scientist debunks the research.


What research? The research in the FPP shows that homebirth is not riskier.

every academic study has shown homebirth to be riskier in the US

please cite.

Because the research in the FPP is a peer-reviewed academic study that does not show that.
posted by MisantropicPainforest at 10:52 AM on March 3, 2014


There is not a single paper published by an independent researcher that shows homebirth to be safe.

I suggest you use google scholar, typing homebirth cochrane review. I also googled Cochrane homebirths Europe in order to sort out those home births which are because of poverty or other reasons for non-access to healthcare. It seems there are several studies. It also seems that these studies find no significant difference for low-risk mothers.
Fun fact: the very inspiration for Cochrane reviews was the hospitalization of normal deliveries!
I am aware that DrAmy has a particular understanding of what "significant difference" implies, but this understanding is not shared by medical (or statistical) research. So the conclusion is: if you are a low risk mother, and you regularly up to the delivery consult with your OB, and you have a midwife with good credentials in terms of education and experience, the risk of giving birth at home is marginal.
posted by mumimor at 11:47 AM on March 3, 2014


if you are a low risk mother, and you regularly up to the delivery consult with your OB, and you have a midwife with good credentials in terms of education and experience, the risk of giving birth at home is marginal.

Europe isn't the basis of comparison. Studies in the US show clearly an increased risk in fetal death, seizure, and hypoxia for home birth babies. It's fine if you decide personally that those risks are outweighed by the desire for home birth. But those risks should be fully disclosed and remediated if possible by better regulation and licensure of CPMs, at a minimum.
posted by yarly at 2:06 PM on March 3, 2014


yarly, that is exactly the point most of us who have had homebirths and believe it is an option that should be available are making.

And those risks were disclosed on the paperwork I completed for my midwife. It was a very detailed informed consent paper.

But you know what wasn't disclosed on the paperwork for my c-section? That I might feel being cut open, that nurses would mix up my chart with someone else's, that lactation consultants would help every mother in the ward but me. And that I was expected to be thrilled about what happened to me because I had a baby. The fact that I was so traumatized I was nearly speechless --- that my doctor breezed in with a, "And how are you emotionally today?" as if, for her, it was just Tuesday --- because for her it was just Tuesday --- and thought my silence of disbelief was that I was okay instead of being just shocked that she could ask such a question of me, that surely she should have known that of fucking course I wasn't doing well emotionally. For me --- it was the first day I started to spiral down a very dizzying staircase.

None of that was disclosed on my informed consent paperwork for the hospital. And it damned well should have been.
posted by zizzle at 4:36 PM on March 3, 2014 [1 favorite]


The Cochrane Review on homebirth is a piece of junk. Read it; it contains only 11 (!) women. Cochrane Childbirth Reviews are noted for their poor quality as compared to other Cochrane reviews.
posted by DrAmy at 4:48 PM on March 3, 2014


Because the research in the FPP is a peer-reviewed academic study that does not show that.

It emphatically does. The MANA study says that homebirths are safe, which may be true for your definition of safe. However, when you compare their numbers with CDC numbers for hospital births, it is clear that home birth mortality rates are higher. You can make the claim that home births are safe, but you cannot say that they are just as safe as hospital births. The absolute risk may be low, but the relative risk is much higher. That's the whole point of this FPP.
posted by snickerdoodle at 4:50 PM on March 3, 2014


zizzle, those all sound like bad experiences, but not as bad as a dead or brain damaged baby. And the informed consent forms I've seen, like this one from Vermont, are not good disclosures. Even if it was a perfect disclosure, disclosure is no remedy for underlying problems in the standard of care. Also, I kind of don't think people are actually capable of consenting to a dead baby. In the event that happened, I'm pretty sure most people would feel like they hadn't actually consented to that, because there is no way of knowing how it will actually feel if your baby dies or is brain damaged because of where you chose to give birth.
posted by yarly at 5:03 PM on March 3, 2014


How is it impossible to understand that some people may be willing to accept an increased, but still very small, risk of a dead or brain damaged baby in exchange for a drastically reduced risk of other bad (but less severe) outcomes? Maybe it's not the choice you would make, but it doesn't make it a poor choice by definition. People make this calculus every day when they put their kids into the car, and nobody accuses them of having a poor understanding of statistics or being woo-woo anti-scientific goombahs.
posted by KathrynT at 5:27 PM on March 3, 2014 [3 favorites]


Also, given how fast she could gave come if it weren't for an arm across her chest, I very well may have ended up giving birth on the side of road while attempting to get to the hospital with no qualified attendant at all.

How it it people are amazed and astounded when a woman gives birth trying to get to the hospital but doesn't and it's considered an amazing feat, but when someone chooses birth attendants to come to them it's considered irresponsible? Babies born on the sides of the road are probably at an equal risk of death as babies born at home. Yet is newsworthy and testament to how astoundung birth is. But it's an unassisted birth and has got to be scarier and far riskier, especially in places where hospitals are not anywhere nearby and ambulance response time is substantial.
posted by zizzle at 5:40 PM on March 3, 2014


The risks of a dead or brain-damaged baby remain very, very low at home, even if they're not as low as they'd be in the hospital. And it's pretty crappy and condescending to dismiss someone's trauma with, "You don't know how shitty you would have felt if your baby had died."

Women matter. Their emotional and physical health matters. They are frequently treated as if they don't in these conversations, so long as you avoid a dead or seriously injured baby. And that's really a big part of the problem--a major reason why women turn to other care models.
posted by PhoBWanKenobi at 6:30 PM on March 3, 2014 [5 favorites]


How is it impossible to understand that some people may be willing to accept an increased, but still very small, risk of a dead or brain damaged baby in exchange for a drastically reduced risk of other bad (but less severe) outcomes?

Dr. Amy aside, I don't think it's impossible at all to understand. Everyone has a different risk calculus, and it's no one's business where you choose to give birth. It is, however, the state's business if medical providers misrepresent the facts by claiming that the increased risk doesn't exist at all, which is exactly what MANA is doing.

You knew the risks and chose to accept them. Wren Jones' parents, on the other hand were told that as long as there were low risk, had a midwife, and were close to a hospital "home births were actually safer than hospitals."
posted by snickerdoodle at 8:39 PM on March 3, 2014 [2 favorites]


The Cochrane Review on homebirth is a piece of junk.
There is not *one* Cochrane review on home birth, there are several, spanning decades and several nations. Which is kind of the point of Cochrane reviews.
posted by mumimor at 11:01 PM on March 3, 2014


While it might not be 'safer' than hospitals, homebirth certainly can be 'better' for everyone involved. And I think that repeatedly trying to pivot away from the OB's culpability in the dismal perception they are subject to by narrowly focusing on this aspect of it to the exclusion of it -- and the apparent exclusion of their own responsibility doesn't present a very 'professional' image.

I would very much like to hear from everyone who suggests that people should prefer hospitalization for birth to tell us what they intend to do with regulation TODAY to ensure the patients best OVERALL interest and happiness and not this rigid aspect of Safety Uber Alles focusing on one limited metric.
posted by mikelieman at 3:51 AM on March 4, 2014 [2 favorites]


It emphatically does. The MANA study says that homebirths are safe, which may be true for your definition of safe. However, when you compare their numbers with CDC numbers for hospital births, it is clear that home birth mortality rates are higher. You can make the claim that home births are safe, but you cannot say that they are just as safe as hospital births. The absolute risk may be low, but the relative risk is much higher. That's the whole point of this FPP.

It is NOT clear that the rate for home birth mortality rates are higher. the base rate for materal death is so low, that tests of statistical significance do not tell us anything. A bad day for one homebirth midwife that results in 3 deaths could throw off the entire pool of data.
posted by MisantropicPainforest at 8:03 AM on March 4, 2014 [2 favorites]


Do you have anything to back up the assertion that the studies cited "do not tell us anything"? My understanding is that the studies show a clear, substantial increase in the risk.
posted by yarly at 12:48 PM on March 5, 2014


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