What’s So Scary About Home Birth?


"The Perils of Home Births" screams the title of the segment at the bottom of the screen in a Today show attempt to cover the realities of homebirth in the United States.

"Is avoiding the clinical nature of a hospital setting for a homebirth worth the risk?" asks the reporter. Never mind that the question seems in part to answer itself with the presumption that there is greater risk inherent in a homebirth. The answer further seems rooted in the devastating story of a young couple expecting their first child. As the story is reported, the couple employed a certified nurse midwife ("CNM") to birth at home. After a four-day labor, the frightening voice-over tells viewers, "overseen not by doctors but by the midwife’s staff…"  the baby is born without a heartbeat, rushed to the hospital and dies from suffocation, a result of becoming entangled in her own umbilical cord. A devastating story with which we all sympathize, to be sure. 

Should this story, however, be used as a reason to employ scare tactics and to encourage non evidence-based decision making for pregnant women looking into their childbirth options?

As Alison Cole, midwife-in-training, notes in her RH Reality Check reader diary on the segment, "My heart aches for this family, but their experience does not shed light on the safety of birthing at home, just as the story of one family mourning the loss of a hospital-born baby is not evidence that all births should be removed from the hospital."

Coincidentally, the same day, I receive in my inbox a notification of a newly released study out of Ontario, Canada published in the most recent issue of Birth journal. The study examines the outcomes associated with planned home-birth compared to planned hospital birth, facilitated by midwives, in Ontario over a three-year period (from 2003-2006). The authors find that, in fact, there is no difference between planned home and hospital birth when comparing perinatal and neonatal mortality rates (or maternal mortality rates, either). 

This is not the first, nor will it be the last, compilation of data confirming the safety of homebirth facilitated by midwives. The results of a study will never comfort a crushed-hearted couple dealing with the death of a child whether born at home, in a birthing center or in a hospital. But the evidence as to the safety of planned home-birth and midwifery care is clear and getting clearer everyday. Unfortunately, with a tremendous lobbying effort and biased agenda, the American College of Obstetricians and Gynecologists (ACOG), continues to use its power to quash access to this kind of care for women in the United States.

Midwifery care, in Ontario, Canada, is regulated by the College of Midwives of Ontario and is widely accepted as optimal care for low risk pregnant women. In fact, in many ways, it is the kind of system many midwifery practitioners and advocates are pushing for in this country in hopes of providing women and their babies with the highest-quality prenatal, perinatal and postnatal care. 

According to the authors of the published study, 

Midwives are well integrated into the Ontario health care system; they have admission and discharge privileges at their local hospital(s), and access to other health care providers for consultation or transfer of care as required. Two midwives are in attendance at births either in the home or in the hospital.

Ontario is not alone in its support for homebirth – nor are the findings an anomaly. The UK’s Royal College of Obstetricians and Gynecologists fully supports planned home birth for "women with uncomplicated pregnancies." Canada’s Royal College of Obstetrics and Gynecology pursued research which concluded that planned homebirth results in positive health outcomes for both mother and baby:

"Women planning birth at home experienced reduced risk for all
obstetric interventions measured, and similar or reduced risk for
adverse maternal outcomes," writes Dr. Patricia Janssen from the
University of British Columbia and coauthors. Newborns born after
planned home births were at similar or reduced risk of death, although
the likelihood of admission to hospital was higher. 

The evidence being uncovered regularly – from around the world – suggests that there is great benefit (for mother and newborn) to ensuring access to midwife-care, homebirth and other out-of-hospital birth options. As well, as Jennifer Block notes, there is a cost effectiveness to increasing access to a range of chidbirth options. When women are subjected to increased, unnecessary medical interventions, costs rise for all involved – families, insurance companies and hospitals. 

Unfortunately, there are significant obstacles to accessing this kind of care for many women in this country. Without regulation and licensure of certified midwives in all fifty states, birthing out-of-hospital with a midwife may be illegal or financially out-of-reach for most women, severely restricting a woman’s freedom to choose to birth in the way she sees fit and forcing midwives into difficult, sometimes career-jeopardizing situations. 

In an attempt to address the reality of how and why midwifery care is out-of-reach for many women, the Today Show segment quotes a source citing the "elite" nature of out-of-hospital childbirth, comparing it to a "spa treatment." And while there is some truth to the idea that access to midwifery and homebirth remain options only for those who can afford to pay out-of-pocket, this is by far the whole story.

While The Today Show is busy running tabloidesque segments on childbirth, advocates and providers are hard-at-work attempting to expand safe, evidence-based options for maternity care for U.S. women and their families . If campaigns like The Big Push for Midwives are able to successfully ensure licensure and regulation of CPMs (and legislation to do this is currently pending in 18 states, according to The Big Push), the demand for this kind of care – no matter what a woman and her families’ economic situation may be – can be met. It means that midwifery maternity care can be covered under various health insurance plans – including Medicaid. In some states, it’s already happening – with impressive results.

In Washington state, for example, all births regardless of health care
provider or location, can be covered under any insurance plan including
Medicaid. As Miriam Perez writes for RH Reality Check, in Washington state, "around
45% of out-of-hospital births attended by midwives in the state are Medicaid
births." Midwifery care becomes accessible for all women, and makes good economic sense, when we ensure safe and regulated care through licensure.  A cost-benefit analysis performed by the Washington Department of Health showed that licensed midwifery care saves the state $3.1 million per biennium.

Despite The Today Show’s insistence on painting midwife-provided maternity care as a cause-celebre, a growing number of U.S. women are choosing to birth out-of-hospital under a midwife’s care. Professional medical assocations like the AMA (American Medical Association) and ACOG are feeling the pressure. An ACOG representative’s blinders were practically visible when she declares in The Today Show segment that "childbirth decisions shouldn’t be dicatated by what’s fashionable or trendy" – as if pregnant women who meticulously and thoughtfully prepare for a home birth, with the support throughout pregnancy from a midwife, are simply making their decision after flipping through fashion magazines, spotting a star’s story of her homebirth and deciding to just "go for it" to be cool or hip. 

Last year, in fact, the AMA went on the offensive, targeting celebrity Ricki Lake’s documentary, The Business of Being Born, in a resolution stating its opposition to homebirth. The outcry, however, was so great that the organization amended its resolution and deleted all references to Lake and her film. 

The Big Push for Midwives has this to say about ACOG’s focus on homebirth as simply another celebrity led trend:

ACOG
clings to this ridiculous fantasy that women choose to deliver their
babies outside of the hospital because they want to be like Ricki Lake,
Demi Moore or Meryl Streep and that if women would only watch enough
fear-mongering stories on morning television they’ll be brainwashed
back into hospitals,” said Katherine Prown, Campaign Manager of The Big
Push for Midwives. “Insulting our intelligence and promoting policies
that deny us choices in maternity care are not exactly winning
strategies for stemming the tide of women seeking alternatives to
standard OB care.”

The Today Show segment does include an interview with a former head of Women’s and Children’s Health at the World Health Organization, Marsden Wagner, who talks about the tendency hospitals have to treat even low risk, healthy pregnancies as medical emergencies. The reporter also acknowledges the rise in unnecessary medical interventions – including a 50% meteoric increase in cesearean sections over the past decade. Jill who writes the blog TheUnnecesearean.com notes that according to the latest statistics from the CDC almost 32% of all births are via c-section in this country. 

What is most important to highlight, ultimately, is that women in the United States are increasingly seeking alternatives to hospital birth for a variety of excellent reasons. For some women it’s a desire to experience their low-risk, healthy pregnancy not as a medical condition but as a natural state – a healthy state – with a provider who encourages them to trust their bodies. Maybe a woman doesn’t wish to expose herself to potentially unnecessary medical interventions, but wishes to create an environment and experience that speaks to the ways in which she and her family envision welcoming their baby into the world – in a way that seems most compatible with midwifery and out-of-hospital care. Other women are distrustful of our health care system’s tendency to treat pregnant women (or any seeker of health care) as merely a consumer or a number without a name, on the receiving end of depersonalized care. Some women view the mainstream medical establishment as patriarchal and demeaning, in general, and reject the idea that "doctor knows best" in any and all situations regarding pregnancy and childbirth.  This is not say that ob-gyns cannot be excellent, loving and responsive care providers. There are millions of us out there who are indebted to these kinds of ob-gyns, undoubtedly. Midwives understand the value and importance of a trusted, respectful physician as a partner in a woman’s care, should she need it. 

The midwifery model of care may be an appealing option for many women because it starts from a place of empowerment – if you can envision it, you can do it. Start with an intention of the kind of birth you wish to have, my midwife and doula told me, and we’ll go from there. Maybe you have a vision of birthing outside but never dreamt it was possible – as one woman on Ricki Lake’s web site writes of her own desire: "I told my midwife of my dream. Her exact words were, “mmmmmm, that
sounds beautiful. Is that something that you would like to do?” That
floored me since I wasn’t at that point asking to have an outdoor
birth." Or maybe you’ll plan for the homebirth you’ve been expecting and midway through your pregnancy, or after hours of labor, your midwife tells you you’ll need an emergency cesearean section, in a hospital. Birth doesn’t always go the way we plan – no matter where or with whom we choose to birth. The issue at hand, however, is not that we can possibly know exactly how it will end up but why we wouldn’t think that we deserve to do everything we can to experience pregnancy, childbirth and the days and weeks postpartum in a way that feels best and right for us – most importantly, winding up with a healthy newborn warm against our chest, asleep next to our body. The Today Show may present homebirth as an option to be feared but that’s only because the unknown is often times a scary venture. If you look at the evidence and listen to women’s experiences, It doesn’t have to be that way.

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  • amytuteurmd

    <p>What’s so scary about homebirth? It increases the risk of neonatal death.</p><br />

    <p>American homebirth advocates continue to celebrate the recent publication of homebirth studies from Canada and the Netherlands. Evidently, they have failed to grasp the central lesson of both studies: homebirth can only be safe when practiced by highly educated, highly trained midwives under rigorously controlled conditions. Since this is in direct opposition to the philosophy of American homebirth, it is not clear what advocates are celebrating.
    The death rates for hospital births in Canada are comparable to the death rates for American hospital births in 2003-2004. However, the homebirth death rate for American midwives is more than triple the homebirth death rate for Canadian midwives.</p><br />

    <p>There are two reasons for this:</p><br />

    <p>1. American homebirth midwives have less education and training than Canadian and Dutch midwives. Canadian and Dutch midwives attend both hospital and homebirths, and therefore have extensive education and training in the recognition and treatment of complications. They receive comparable training to American certified nurse midwives.</p><br />

    <p>2. There are strict eligibility requirements for homebirth in Canada and the Netherlands. You can’t have a homebirth simply because you want one. You must be very low risk because anything else is considered too dangerous.</p><br />

    <p>Homebirth with an American homebirth midwife can never be safe unless the midwives are held to a higher standard. Their level of education and training must be brought up to the same level as midwives in every other first world country. Homebirth must be subjected to the same eligibility requirements as in other first world countries. Unless standards are raised, babies will continue to die unnecessarily at births attended by American homebirth midwives.</p>

  • mary-beth-hastings

    Amy, I’ve seen your posts on other sites on this issue, and what makes you much less credible in my eyes is that you use this term, "homebirth midwives."  There’s no such job title.  There are CNMs – like the one who was present at my second daughter’s wonderful birth in my home – and there are CPMs – Certified Professional Midwives who learn through lengthy apprenticeships.   Where they attend births does not convey how much training or education they have.  CNMs can attend births at home, in hospitals, or in birth centers. 

    So please stop using language that seems to be geared toward confusing those unfamiliar with these terms.  It makes you seem as if you just have an agenda of scaring women away from homebirth, which as many studies have pointed out, is safe for low-risk pregnancies.

    I know many women who have chosen to birth with CPMs after extensive research.  Of course, comfort level with a provider is extremely important.  If you have a provider with all the experience and training in the world, but that person doesn’t listen to or respect what you’re saying, outcomes are likely to be worse. Stress during childbirth is highly associated with negative outcomes, and can stall labor.

    Listening to women is the key.

     

     

     

  • juliejulie

    This is a sad story, but not indicative of homebirth outcome! Midwives are amazing and I would never go through a pregnancy without one. I had a team of midwives and attempted a planned homebirth. After 30 hours of labor, my excellent team transferred me to the hospital because it had been more than 24 hours since my water broke. I find the story described on the Today Show hard to believe…what CNM or HOSPITAL for that matter would allow labor to continue this long without intervening? Terrible, sad story, but not at all representative of Homebirthing. Our society tries to handle pregnancy and birth as a sickness, a disease, when it is in fact an inexplicable miracle that no one can fully predict or comprehend. If I were to have another child, I would attempt homebirth again, I would have midwives again, and no matter what, I would never set foot into a hospital as a pregnant woman without my midwife. My midwives saved my life and my baby’s life in the hospital. Without their attentiveness and care, the hospital staff would have missed some crucial facts and let us languish.

  • amytuteurmd

    "what CNM or HOSPITAL for that matter would allow labor to continue this long without intervening?"

     

    What CNM? Cara Muhlhahn, CNM.

     

    This was not the first neonatal death attributed to Muhlhahn’s failure to transfer a patient. This is at least the second death. According to a NY Magazine profile, Muhlhahn lost a baby who was born needing and expert resuscitation and she couldn’t resuscitate the baby.

     

    Most doctors will never experience even a single intrapartum death during a career of thousands of deliveries. This midwife has already had two, and both, not surprisingly, occurred at home.

     

    The scenario may seem incredible to you, it is an example of why homebirth has an increased rate of neonatal death. The statistics I quote are real, and no professional homebirth advocates would deny it. Instead they refuse to discuss it.

  • amie-newman

    thank you for the comment. I couldn’t have put it better myself. The key here, as you say, is listening to women. Dr. Tuteur is so tied to the presentation of statistics and studies that confirm what she wants so badly to be true but what simply isn’t a cut and dry situation. In fact, as my piece addresses (and many other articles on this subject note), there are just as many studies confirming the safety of planned homebirth for low-risk pregnant women.  As Mary Beth writes, what Dr. Tuteur calls "homebirth midwives" are Certified Professional Midwives and must be certified by the North American Registry of Midwives with strict requirements for certification.

    Dr. Tuteur, these lines from your comment are telling:

    You can’t have a homebirth simply because you want
    one. You must be very low risk because anything else is considered too
    dangerous.

    "You can’t have a homebirth simply because you want one" is at best condescending and, truly, reductionist in its attempt to discuss the out-of-hospital childbirth option. First of all, "simply because you want one" is actually a wonderful reason to remain open to all of one’s options for pregnancy and childbirth care. Listening to our minds and bodies and trusting our own sense of what feels right for ourselves and our babies’ is probably the best way to start off the decision-making process for pregnancy and childbirth. Secondly, what I read in that statement is an inherent distrust of a woman’s ability – and a Certified Professional Midwive’s skillset – to make a measured, informed, thoughtful and, above all, safe choice for her baby’s and her own care. The midwifery model of care is premised on the idea that pregnancy and childbirth are healthy, normal conditions, ensuring that the woman will receive personalized care with minimal medical intervention – unless medical care is needed. In this case, the model of care is clear: women are referred for obstetrical care. 

    Dr. Tuteur, I know your studies. You post them on every article on our site (and many other sties) and use them as a way to discredit the valued work that midwives perform in this country. Additionally, The Big Push for Midwives are working hard to ensure licensure and certification for CPMs around the country in order to improve access to safe care for women in the U.S.

    Certified Nurse Midwives, to which the commenter Mary Beth refers, are also an excellent resource in this country – providing care for pregnant and birthing women at both in-hospital and out-of-hospital settings. There are many CNMs who are extremely supportive of the campaign to expand these birthing options for women. I was lucky enough to have a CNM at my first birth where there were complications that needed immediate attention – and I encourage any and all women to look into their full range of health care options, do the research and trust themselves.

    Amie Newman

    Managing Editor, RH Reality Check

  • amytuteurmd

    "Dr. Tuteur is so tied to the presentation of statistics and studies
    that confirm what she wants so badly to be true but what simply isn’t a cut and dry situation."

     

    If I understand you correctly, you are acknowledging that the information I have presented is factually correct. I appreciate that.

     

    So here’s my question:

     

    Since CDC statistics show that homebirth increases the risk of neonatal death and since the training of CPMs does not meet the standards for midwives in any first world country, why don’t you mention that? Aren’t women entitled to complete and accurate information about homebirth?

  • amie-newman

    I’m not sure why you would cite anecdotes as some sort of proof of anything? It’s EXACTLY what the Today Show did in its sloppy excuse for reporting. I can cite a million midwives who have never (thank god!) experienced one death of a newborn or mother under their care. I can cite at least 3 women I know who devastatingly lost babies under the care of ob-gyns. It is not "evidence" of anything. It’s not about the stories you or I tell. It’s about the studies and the research AND about what millions of women are choosing with the health and safety of their babies and themselves in mind.

    On the other hand, evidence does show that the inexcusable number of unnecessary medical interventions experienced by women and babies in hospitals in this country (especially if you are African-American and are four times more likely to die during childbirth than a white woman) result in poorer health outcomes for both.

    Honestly, for all those who are interested, please just read this comment thread and it will answer all of your questions about Dr. Tuteur’s "evidence".

    Amie Newman

    Managing Editor, RH Reality Check

  • amie-newman

    you didn’t understand correctly. What I meant to convey was that you use research and analyze studies in such a way as to make them conform to your own agenda. It makes sense because you hold such strong beliefs – under no circumstanes do you want women birthing at home, with a certified professional midwife.

    Again, I will refer people to Amy Romano’s excellent post on the research released this summer on planned homebirth vs planned hospital birth in Canada. As one of the researchers noted, "there is often no definitive cause for intrapartum death." 

    As Amy writes of the Canadian study, "No study of home birth will be perfect, but large perinatal databases
    and systems that integrate rather than marginalize home-birth midwifery
    have helped to achieve the “scientific rigor” that the American College
    of Obstetricians and Gynecologists has called for. And the results are
    looking very good indeed."

     

    Amie Newman

    Managing Editor, RH Reality Check

  • cpcwatcher

    We have this lovely little notion that the big, strong male doctors “saved” women and babies’ lives when they lobbied to move birth into the hospital in the early 1900s.

    This notion is false. Neonatal death increased with the big move to hospital birth, as did maternal death. The rate did not improve until the discovery of penicillin, and until the Natural Birth movement of the 1960s and 70s, the infant/maternal mortality rates still soared higher than the midwife-attended home birth, which stayed relatively stable throughout. The mortality rates in home birth went down alongside hospital birth once penicillin was better accessed by midwives, and have stayed consistently below the rates in hospital birth.

    The reason? Hospitals treat pregnancy and birth like a disease. Doctors (OBs are *surgeons*) spend the entire labor looking for something that’s “going wrong” with the mother or baby, and love love LOVE to cut, snip, operate… it horrendous.

    If home birth was unsafe, we’d have died out hundreds of years ago. Women’s bodies are not so untrustworthy that you need consistent fetal monitoring in every last labor.

  • amytuteurmd

    You know as well as I do that my statistics are factually correct. You won’t say otherwise because that would be untrue and it’s easy to prove.

     

    As far as Amy Romano is concerned, she won’t even allow my comments to be posted on her site because she is unable to counter them. This is what I mean about homebirth advocates. They don’t tell the truth and they try to muzzle anyone who does.

     

    Frankly I think it is unethical for Amy Romano, Jennifer Block and Henci Goer to try to insulate themselves behind comment systems so that no one will know the truth about neonatal death at homebirth.

     

    I certainly appreciate the fact that you are willing to let me air the facts. I’m just disappointed that you don’t air them yourself, as if women don’t have an absolute right to know them.

  • bloomspokane

    Amy,
    Nice work! I congratulate you on having written one of the most thorough and convincing rebuttals to the Today Show piece. My husband and I were appalled by the show’s lack of journalistic integrity and misrepresentation of facts. We wondered if Today’s parent company, GE (and the fact that they make medical equipment for hospitals), has anything to do with the obvious pro-hospital bias of the story.

  • amie-newman

    for your claim that newborn mortality rates in Canada are equal to the rates in the U.S.
    It is without debate that the U.S. has the second worst newborn death rate in the developed world. 

    I’d also love to see links. 

    Our maternal mortality rates are equally as dismal.

    But health experts agree that there are many reasons for our horrendous infant and maternal mortality rates in this country – not one of which is greater access to qualified, certified professional midwives or out-of-hospital childbirth. 

    In fact, as so many note, our women and newborns are dying in American hospitals under the care of ob-gyns. Reasons for our horrendous mortality rates can be found here

    One more time, for anyone who is interested, Jennifer Block offers an excellent analysis in her piece, "Where’s the Birth Plan?" that provides a point/counterpoint for any of Dr. Tuteur’s claims. 

    Amie Newman

    Managing Editor, RH Reality Check

  • mary-beth-hastings

    Dr. Tuteur – You obviously feel very strongly about this – and I frankly haven’t looked at all the studies you mention.  But even as you claim home birth advocates ignore the facts, it seems that you only look at those facts that appeal to you. And even as you claim we ignore your studies (even though other evidence has been presented to you) you haven’t once dealt with the risks and disadvantages of hospital births, even though these births account for almost all of US births.

     

    Facts are different from truth.  The truth is, the risk of neonatal death in any case is low.  It is ALWAYS IMPOSSIBLE to know if a neonatal death would not have occurred if the birth took place somewhere else.  You can try to make assumptions, but no one knows for sure.

     

    The question the TODAY show posed is: does the benefit outweigh the risk?  Clearly, many women decide the answer  is yes – EVEN when they look at your cherrypicked statistics, Dr. Tuteur!  And why is that?  It’s because women often experience the medical system as an uncomfortable place where they are treated without respect.  And a place where women’s natural and amazing power to give birth is subverted to the systems that make doctors more comfortable and safe. 

     

    You may counter that respect isn’t important – everyone’s top priority should be avoiding a higher risk of infant death (and this is not to say that I accept your stats as truth).  Well, should avoiding a risk of death drive our decisions always?  Should I keep my six year old home from school because she might catch the swine flu?  Should I make my kids wear helmets when walking across the street in case they get hit?  Should I not let them in the bathtub since they could slip and fall?   Life is risk – and that applies to childbirth as well.  

     

    While hospital birth is absolutely a right, it should not be compulsory.  And unfortunately, that’s what the AMA and ACOG are trying to mandate.

  • jayn

    Amy, you talk about everything in percentages–’risk of death is three times higher’.  Okay, that may be true…but we’re talking about something that occurs less than once in a thousand births.  Three times nothing is still nothing.  Meanwhile the mother gets to deliver in a more comfortable setting, and hospital resources can be redirected towards those mothers who do need the extra medical attention, or who feel more comfortable in a medical setting.

     

    Also, there’s more than just the baby involved in the birthing process, and I have yet to see you comment on the outcomes for mothers.

  • amytuteurmd

    I’m happy to respond because this is one of the most commonly quoted statistics that is entirely wrong.

     

    First, it is important to understand that there are 3 different kinds of mortality: infant mortality (birth to 1 year), neonatal mortality (birth to 28 days of life) and perinatal mortality (from 28 weeks of pregnancy to 28 days of life.

     

    The statistic you are referring to is infant mortality, which is a measure of pediatric care since it includes death up to 1 year. You are correct that it is not nearly as good as European infant mortality statistics.

     

    Neonatal mortality is a measure of obstetric care and perinatal mortality is the internationally recognized standard for measuring obstetric care. That’s because different countries have different ways of measuring neonatal mortality. For example, the Netherlands counts very premature babies as stillbirths even when they are born alive. That’s one of the reasons why the Dutch neonatal mortality rate is lower than the US. They simply eliminate premature babies while we count them.

     

    The World Health Organziation recommends using perinatal mortality as the best measure of obstetric care because it includes late stillbirths, and deaths during labor as well as neonatal deaths. According to the 2006 WHO report, the US has one of the lowest neonatal mortality rates in the world, lower than England, Denmark and the Netherlands.

     

    The truth is that the US obstetric system is among the best in the world. That’s what the WHO says.

     

    This is yet another example of deceptive tactics on the part of homebirth advocates. I’m sure that you were not aware of the distinctions between infant, neonatal and perinatal mortality. Therefore, you never realized that professional homebirth advocates were deliberately quoting the wrong statistic. The correct statistic is perinatal mortality, and in the absence of that data, neonatal mortality is a reasonable second choice.

  • amytuteurmd

    "Risk is not avoidable"

     

    Of course it is; that’s the whole point of preventive care, minimizing risk, and obstetrics is preventive care.

     

    Do you put your infant in a carseat? That’s because it reduces the risk of your baby dying in the event of an auto accident, right? You do that even though the risk of a baby dying in a car accident is LESS than the risk of a baby dying in labor. If you think minimizing the risk of death from a car accident is important, then you ought to think that minimizing the risk of death in labor is important.

     

    My main point is that women are being denied the information they need to make an informed choice. If you want to have a homebirth, go ahead and have a homebirth. But if you don’t know that homebirth nearly triples the rate of neonatal death then you aren’t making an informed decision. And if celebrity homebirth advocates (who are well aware of this information) didn’t tell you that homebirth increases the risk of neonatal death, but actually told you the opposite in an effort to sway your decision, you can’t possibly make an informed decision.

     

    You don’t have to take my word on any of this. The databases and the national statistics and the studies are out there. You do have to read them, though, and the easiest place to start is with the national statistics at the CDC Wonder website. It is incontrovertible that homebirth with a homebirth midwife has nearly triple the neonatal death rate of hospital birth for comparable risk women. It is incontrovertible that homebirth with an American homebirth midwife has triple the neonatal mortality rate of homebirth in Canada or the Netherlands.

     

    I encourage everyone to look at the data for themselves. At the very least it will help you understand that celebrity homebirth advocates have not been honest about the danger of homebirth.

  • alison-cole

    I have not read all the comments, but I would like to know, if Dr Amy is right about the increased death risk for babies born w/ CPMs at home, why the prestigious British Medical Journal, where the 2005 study on the statistics of N American CPMs was published showing no increased risk for babies born with CPMs outside the hospital, has not published a correction or publicly recanted their publication of the study?

  • amie-newman

    Dr. Tuteur,

    Thanks for the clarification and your statistics above make sense. Although, again, I would add that for African-American women who are four times as likely to die during childbirth in this country (in a hospital) these stats are probably not very reassuring.

    That said, there is still nothing there that a) makes an argument against expanding pregnancy and childbirth options for women in this country or b) addresses the extraordinarily harmful, rising rates of unnecessary c-sections in this country or c) speaks to the negative outcomes associated with over-medicalizing childbirth by promoting unnecessary medical interventions or d) opposes the fact that the World Health Organization and any and all NGOs working to improve maternal and newborn health in this country and around the world encourage the use of skilled birth attendants – whether we’re referring to a midwife or a doctor – to improve women’s and newborn’s health and chances of survival post-birth.

    I have never read anything, anywhere from a reputable source – aside from biased information coming out of ACOG and the AMA (and your own web site) – that discourages women from birthing out-of-hospital (at home or in a free-standing birth center) with a skilled midwife, if they so choose. 

    All Certified Professional Midwives, Certified Nurse Midwives and many physicians who support them are working towards is the availability and accessibility of safe childbirth options for women. You may believe, with all your heart, that out-of-hospital birth is not as safe as hospital birth but I still haven’t seen anything that proves this to be true (I would love to see a link to the CDC data to which you refer in your initial comment). I have, however, read volumes on the safety of home birth under the care of a CPM for women with low-risk, healthy pregnancies. 

    Amie Newman

    Managing Editor, RH Reality Check

  • amie-newman

    First of all, you use statistics that you seem to spend hours dissecting and molding in order to try and fit your own anti-home birth anti-certified professional midwife crusade. But where are the studies, published in peer reviewed journals that support your endless jigsaw puzzles of numbers and statistics? If you end up publishing a study in a peer-reviewed journal, I would be more than happy to write about that. But, for now, we have peer reviewed studies from around the world (many referenced in my post and in comments) that provide evidence as to the safety of out-of-hospital, midwife facilitated birth.

    Dr. Tuteur, you cannot provide links or statistics or peer reviewed, published studies that prove any of your points because they are not there. 

    You may chose to avoid or deny the evidence and, of course, you can twist and pull and stretch statistics how you see fit. The truth – the evidence based truth – is that both planned home birth and planned hospital birth in the U.S. are equally as safe. The truth is that Certified Professional Midwives in this country must meet rigorous certification requirements before attaining certification. The truth is that many physicians around this country work in concert with CPMs to provide high quality, evidence-based care for women in pregnancy and childbirth. 

    Thanks for commenting. 

    Amie Newman

    Managing Editor, RH Reality Check

  • amie-newman

    I appreciate your kind words and I share your suspicions, fyi :).

     

    Amie Newman

    Managing Editor, RH Reality Check

  • amytuteurmd

    "you cannot provide links or statistics or peer reviewed, published studies that prove any of your points because they are not there."

     

    Of course I can. Take the Johnson and Daviss (BMJ 2005) study. It actually shows that homebirth with a CPM has nearly triple the neonatal mortality rate of low risk hospital birth.
    The study is available for free, so anyone can read it. I want to call your attention to a specific point. Johnson and Daviss performed two different home-hospital comparisons. First they compared the interventions at homebirth to low risk hospital birth:

     

    "We compared medical intervention rates for the planned home births with data from birth certificates for all 3 360 868 singleton, vertex births at 37 weeks or more gestation in the United States in 2000, as reported by the National Center for Health Statistics [Births: final data for 2000. National vital statistics reports. Martin JA, Hamilton BE, Ventura SJ, Mencaker F, Park MM. Hyattsville, MD: National Center for Health Statistics, 2002;50(5)]"

     

    Then they compared the neonatal mortality rate of homebirth to … a bunch of out of date studies extending back to 1969. The obvious question is: why they didn’t compare neonatal mortality rates to the exact same group they used for interventions? That’s because hospital neonatal death rate for low risk babies at term in 2000 was 0.9/1000 (uncorrected for congenital anomalies, pre-existing medical conditions, pregnancy complications or multiple births). The true rate is substantially lower.

     

    Nonetheless, we can make an important comparison. Johnson and Daviss reported a neonatal death rate at homebirth of 2.6/1000 (uncorrected for congenital anomalies, breech or twins). The neonatal death rate in the comparison group THAT THEY USED was less than 0.9/1000.

     

    So now we have an explanation for why Johnson and Daviss used two different comparison groups. They used one group (births in the year 2000) for comparing medical interventions. The neonatal death rate in that exact group was 0.9/1000, a third the rate of neonatal deaths at homebirth. They supressed that information by using an entirely different group (drawn primarily from the 1970′s and 1980′s) instead of using the death rate from the year 2000.

     

    Johnson and Daviss have acknowledged on their own website that they used the wrong comparison group, but they claimed that the information was unavailable to them:

     

    "… Since our article was submitted for publication in 2004, the NIH has published analysis more closely comparable than was available at that time, and some have tried to use it as a comparison. While we still do not offer the comparison as a completely direct one, as it is the closest we have and the comparison is occurring regardless of our cautions, we offer the following adjustments that have to be made to provide the comparison of the CPM2000 analysis in as accurate a manner as is possible with the published NIH analysis."

     

    But that excuse is simply untrue. The data was published in 2002, years before they submitted their paper to the BMJ.

     

    There is literally not a single paper on American homebirth that shows homebirth to be safe, not a single one. Even the papers that claim to show homebirth is safe actually show the opposite.
    As I said before, if a woman wants to have a homebirth, she can have a homebirth. However, she cannot make an informed decision is she doesn’t know the truth.

  • amytuteurmd

    "The truth – the evidence based truth – is that both planned home birth and planned hospital birth in the U.S. are equally as safe."

     

    No, that’s not the truth. That’s what I am trying to explain to you.

     

    I understand that that’s what you’ve been told by other homebirth advocates, but they either don’t know the truth (haven’t read any of the actual papers) or refuse to divulge the truth.

     

    Please, please, please read the actual studies, examine the national statistics, read information sources other than homebirth advocates. You need to understand that the ONLY people who think homebirth is safe are homebirth advocates themselves. Everyone else knows the truth.

  • mary-beth-hastings

    So your main point is that women aren’t hearing enough of the AMA’s position on home birth?  They had a whole spot on the TODAY show, that I believe they didn’t even have to pay for!  And they have the most powerful medical lobby in Washington.  And a whole lot more money and power than all midwife organizations and home birth advocacy groups put together.  And heck, TV shows based on hospitals seem to have a tragic labor outcome every other week – not to mention "A Baby Story" which is based on the drama of labor gone wrong.  Believe me, likely every woman who has ever had a home birth has faced skepticism from someone.  It’s not a secret message.  Really.  So you can relax.  Your work is done.  women have heard your side of things, but the ones who have chosed to have a home birth anyway have decided that they are comfortable with their decisions.

     

    And what I said -  "risk is not avoidable"  – is not the same as "risk cannot be minimized."  (also, it seems unlikely that there are more infant deaths in home births than there were in car accidents before car seats, but you can check the stats on that, I’m sure!)  Our decisions about risk are always calculated – we do things to minimize risk as much as possible weighing other things.  For me, the risk of major surgery and unnecessary medical interventions that are so common in hospitals was bigger than the tiny risk that something would happen to the baby that would be worse at home (1/4 mile from a hospital) than in a hospital. 

     

    Again, women have done the research and made their decisions. To suggest that women make such a decision based on what a celebrity has said or done really is insulting, so I suggest you take that out of your rhetoric.

  • jayn

    The rates of infant death are minute no matter how you slice things.  The risks may be slightly higher for homebirth (if your numbers are to be trusted–for the sake of argument I’ll assume they are), but if you’re going to claim that an event with at most a quarter of a percent chance of resulting in death isn’t ‘safe’, then I have to ask–what is?

  • amie-newman

    I know we will just go around in circles endlessly – you seem to believe that all of the studies that have come out in recent years - published in medical journals – are all wrong. You keep claiming there are studies that back up your claim that home birth is dangerous in this country and yet refuse to provide links.

    You keep claiming that home birth is 3 times as dangerous as planned birth in a hospital based on statistics you clearly sit at home tweaking over and over again though have curiously never been confirmed, reported on or published – and, yet, as the commenter Jayn astutely points out (and, for what it’s worth if you check any of the links to the threads you’ve been involved in over the last few years that I’ve posted in other comments, many others as well):

    Amy, you talk about everything in percentages–’risk of death is three
    times higher’.  Okay, that may be true…but we’re talking about
    something that occurs less than once in a thousand births.  Three times
    nothing is still nothing. 

    You condescendingly presume to think that those of us who support out-of-hospital birth and certified professional midwifery as safe options for women in this country are not informed or knowledgeable which is simply not the case – as much as you wish it were. 

    Dr. Tuteur, you are simply not credible in this matter and there has been NO ONE who has backed you up in credible articles or studies. It’s you, in your home, running numbers and commenting on blogs in an effort to sway people. 

    I have tried over and over again, in our commenting streams, to engage you in a productive discussion. However, it’s not feasible any longer.

    I encourage you to have your articles published, to put together your own studies and get those published so you can effect change. Commenting on blog posts endlessly won’t do it and thus far there aren’t many in the research community who agree with you either.

    Thanks,

    Amie

    Amie Newman

    Managing Editor, RH Reality Check

  • amberlparker

    While I thoroughly enjoyed the article, as well as the ensuing conflict between Amie Newman and Dr. Tuteur, I am disappointed to see a lack of problem solving- does this discussion do ANYTHING to improve neonatal and maternal outcomes? What are we doing to improve midwifery education? What are we doing to decrease unnecessary medical intervention inside hospitals? How exactly can we bridge the gap between doctors and midwives and provide the very best care to women? Doctors could learn so much from midwives in the management of normal birth, and Midwives must have a complete understanding of pathology- a lesson they can easily learn from the medical community.

    Can we really only offer women a polarized maternal health care system? I think we can do better. But, if we are to make that happen, we first need to care more about the women we are serving than winning an argument.

  • amytuteurmd

    "I know we will just go around in circles endlessly"

     

    Yes, you and I will go around in circles endlessly, but there is a way to settle this. I have a proposal for you, actually two proposals.

     

    1. I’m sure you would agree that American women deserve to know the truth about homebirth. The best way to do that would be to present the information from both sides in a way that everyone could understand and make their own decisions.

     

    I propose that RHRealityCheck sponsor a homebirth debate. I am willing to debate any professional homebirth advocate at any time. I would welcome the opportunity to present my claims side by side with those of homebirth advocates. I am very confident that when women see the actual data, they will realize that professional homebirth advocates have not been completely honest about the safety of homebirth.

     

    Of course, the real problem will be finding a professional homebirth advocate willing to debate. They know what I know and they know that if they are forced to publicly defend their claims, they will be unable to do so. Hence they will do anything possible to avoid a debate.

     

    Last year I was invited to participate in a childbirth conference by the organizers of the conference. They thought that my controversial status in the homebirth community would be an excellent draw. I agreed that I would attend the conference, but with one condition attached. I would only appear in a debate with a professional homebirth advocate, many of whom were already planning to attend.

     

    The conference organizers thought this was a great idea. I warned them that no one would agree, including those who were already planning to attend. Professional homebirth advocates never appear in any forum where they can be challenged by people who are equally knowledgeable. Sure enough, much to the surprise of the organizers, they were turned down by almost everyone. Ultimately they managed to cajole a very prominent homebirth advocate into participating and I made plans to attend the conference. Then, predictably, the homebirth advocate announced that he had changed his mind and would not participate. I did not attend the conference.

     

    I’m hoping that you could be more persuasive, but I am not optimistic. Professional homebirth advocates are afraid of me, and anyone else who has command of the data and scientific literature. They cannot afford to appear in any type of debate because their claims would be eviscerated in short order.

     

    2. Since it is highly unlikely that any professional homebirth advocate would participate in a debate, I offer an alternative way of settling the controversy. Let’s hire a professional statistician to analyze the data and present his or her findings to the public. We could find a mutually agreeable statistician who has no previous connection to the homebirth issue. I am so confident about the results that I am willing to pay for the analysis by any mutually agreed professional statistician.

     

    We may not be able to solve the controversy by arguing with each other, but you, in your role as a professional journalist, are capable of presenting a public analysis of the evidence, either by sponsoring a debate or by agreeing to publish the results of an independent statistical analysis.

     

    Check with the executive staff of RH Reality Check and see what they think. It seems like the perfect forum. RH Reality Check is committed to providing women with accurate information on reproductive health topics. This is a chance to inform the public and get lots of publicity and traffic as a result. And, as I said, I’d even be willing to pay for it.

  • julie-watkins

    Three times nothing is still nothing.

    I haven’t researched childbirth options, so I’m an observer watching this debate … and I don’t have a high opinion of your avoidance of this question (asked multiple times, I think, in various forms). From what I’m seeing: the there’s (debatably) a higher risk for some problems — but about 10 or 100 times less likelihood of an unnecessary ceasarian or other unnecessary surgery. Plus much affordable (especially with less recovery time for the mother figured in).

  • amytuteurmd

    I can’t post the data that you want because the last time I did it was deleted as "spam." I’m not going to link to my website because that might be deleted as spam, too, but it is easy enough to find. All the information you could want is there.

  • ctbirthadvocate

    What it all comes down to is the right to choose where someone wants to give birth. Simple as that. It is not up to anyone but the pregnant woman to make that decision, including the government.

  • ctbirthadvocate

    The best? LMAO! Women being forced to have unnecessary surgery because their hospital doesn’t offer something like VBAC is not the best in the world by any means.

  • juliesunday

    "I propose that RHRealityCheck sponsor a homebirth debate. I am willing to debate any professional homebirth advocate at any time."

    Really? What is this, Crossfire? I can’t imagine the utility of such a debate: homebirth advocates are in favor of women having choices and homebirth haters are not. Is there risk inherent in childbirth, regardless of context? Yes. Those low-risk women who choose homebirth–my mother among them–prefer the risk of homebirth to the risk of some douchebag physician forcing interventions upon them that they do not want and are probably neither necessary nor beneficial to mother or baby.

    RH Reality Check is clearly a site devoted to thoughtful discussion and analysis of reproductive health choices, not efforts to limit them. Frankly, I’m not sure why Dr. Tuteur hasn’t been banned from this site.  Isn’t trolling prohibited?

     

  • maryf

    Seriously, when was the last time that a question of science was “settled” by a public debate? 1850? Debates are “won” by those with superior debating skills, not necessarily a better command of facts.

    As for your second suggestion, if you are willing and able to fund a scientifically valid statistical analysis of birth records, and you are certain that such a study could reach a definitive answer, why haven’t you done so already? So arrange a partnership with a respected epidemiologist, public health expert, and statistician, do the numbers, and submit the results for peer review. Publish it.

    We have an established path for using research tools to answer questions about public health issues. I am aware that there have been a number of notable failures recently in the peer review process, but it is still the most effective means of seeking a truthful valid answer to scientific questions. It really doesn’t matter whether your “research” can convince a group of lay people, or home birth authors, or blog readers. It matters whether you can convince other reputable scientists, researchers, and experts who can review your methods knowledgeably. And so far, you have not presented any evidence that you are willing or able to make that attempt.

  • amberlparker

    This idea of public debate is compelling, but I just have one question- If you would like a “professional home birth advocate” to participate in the debate, shouldn’t we also be provided with a professional in the debate? Because you, Dr. Tuteur, are no longer a professional in the birth world- and haven’t been since 2003 when you let your license lapse.

    Find us a practicing, professional person to debate and maybe we could move forward.

  • amberlparker

    This idea of public debate is compelling, but I just have one question- If you would like a “professional home birth advocate” to participate in the debate, shouldn’t we also be provided with a professional in the debate? Because you, Dr. Tuteur, are no longer a professional in the birth world- and haven’t been since 2003 when you let your license lapse.

    Find us a practicing, professional person to debate and maybe we could move forward.

  • homebirthmama

    Your saying that Home Birth will, most likely end in the death of your child? (Right?)

    Well I had my first (and only thus far) child at home at 17. He is now a happy HEALTHY 17 month old. I would not have a child any other way. It is greatly upsetting that you can sit there and trash home birth but refuse to give links to the statistics that you keep talking about.

    and i agree with Amberlpaker.