A study published this month on the safety (or lack thereof, as the case may be) of homebirth in the American Journal of Obstetrics and Gynecology (AJOG) blazed through the internet amidst a fire-storm of thoughtful, if not frustrated, responses to both its conclusions as well as its methodology. While many are saying the study concludes that home birth is less safe than hospital birth, the results, methodology and politics of the issue require further examination.
Jennifer Block, author of the book Pushed: The Painful Truth About Childbirth and Modern Maternity Care quickly picked up on the political nature of the results and commented on the treatment of the study in the media noting:
Home birth is hotly controversial, so you can bet that when any study about it is released it gets thoroughly dissected (or torn to pieces) by the side bound to clash with its conclusions.
She’s right, of course. Home birth does ignite passion on the part of those who support access to home birth as well as those who seemingly oppose greater access to out-of-hospital and home birth. But as our understanding of just how political this issue truly is emerges, it’s important to analyze the “evidence” provided by certain studies and researchers before we take the conclusions as proof of anything (except, maybe, that said researcher/s hold some strong beliefs around birth and maternity care in the U.S.).
The study, a meta-analysis (an analysis of the data from previously conducted studies, essentially), led by Dr. Joseph Wax, of the Maine Medical Center’s Department of Obstetrics and Gynecology looked at 15 independent studies and came to a conclusion not about the safety of a planned home birth for a woman vs. a planned hospital birth but about “significantly elevated neonatal mortality rates” as the result of a decreased rate of interventions (such as episiotimies, c-sections, and fetal heart rate monitoring) in home births.
The problem with this meta-analysis is multi-layered. The objective, according to researchers, is to “systematically review the medical literature on the maternal and newborn safety of planned home vs planned hospital birth.” But the conclusions are related to levels of medical intervention and the way the rate affects neonatal outcomes – results which then cause the researchers to leap to the conclusion that planned home birth is not safe, rather than build a sturdy bridge to said conclusion. The American College of Nurse-Midwives agrees and says, “this conclusion cannot be drawn from the data presented in the meta-analysis.”
ACNM first points out the problem with the researchers’ decision to use discredited studies:
A meta-analysis is a useful exercise when the studies included are credible and a clear and consistent methodology is presented. In this publication, we are puzzled by the authors’ inclusion of older studies and studies that have been discredited because they did not sufficiently distinguish between planned and unplanned home births—a critical factor in predicting outcomes. Also troubling is that several recent credible studies of home birth were excluded for no apparent reason.
Then there is the issue of those researchers whose data was actually used in the meta-analysis calling it “politically motivated” and “deeply flawed.”
In an interview, Dr. Patricia Janssen, an associate professor at the University of British Columbia, and one of the researchers whose previous data was used in the analysis, told The Globe and Mail that:
“the conclusion is “sensationalist” and based on data that are in some cases decades old, on very small samples and in some cases incomplete.
In many cases, she says, women included in the studies may not have planned to give birth at home. They may not have been attended by a properly trained midwife. And much of the data used were retrospectively, gathered using birth records, which may not include enough information.”
As Jennifer Block notes, Dr. Michael Klein – a fellow University of British Columbia professor who has also published findings on the safety of home birth, hotly disputes the findings:
“It’s a politically motivated study that was motivated by the American College of Obstetrics and Gynecology (which) is unalterably opposed to home birth, and they probably were quite happy to publish this article because it fits with their political position,” he told the CBC.
Beyond the politics of this issue, there are deficiencies in this meta-analysis that cannot be denied. As ACNM points out, only three of the fifteen studies “clearly distinguish between planned and unplanned home births” and those three studies which “comprise 93% of the women used in the entire meta-analysis” found no significant difference in perinatal outcomes.
In addition, says ACNM, there were varying definitions of neonatal mortality – a problem when you’re using neonatal mortality rates as a measurement for the safety of planned home birth vs. planned hospital birth, no?
Only one study (deJonge, et al 2009) both meets the gold standard for quality in home birth research (Vedam, 2003) and had sufficient numbers on which to base conclusions about neonatal mortality.
This study examined early neonatal mortality and found that babies born in planned home birth were not more likely to die or to suffer severe illness in the first week of life. It is not clear why deJonge’s data were excluded in Wax’s analysis of neonatal mortality, despite the fact that this study alone accounts for the majority of the sample in the full metaanalysis.
The push for greater choice in childbirth – from where one births, to what type of provider facilitates the birth, to how one births (ie via c-section, vaginally, with an epidural or without) – has become no less than a movement over the last few years. There is certainly a grassroots element - more and more women are fed up with a patriarchal health care system that wrested control over birth away from them many years ago and placed it squarely in the hands of medical doctors and hospital administrators. As more women with healthy pregnancies birth safely and happily with midwives and out-of-hospital birth, the realization that birth is not by definition a medical infirmity spreads throughout the country and the revelation that women hold the ultimate power over their own bodies, whether before, during or after pregnancy and childbirth, grows. Midwives have taken a stand, pushing for legalization in states where their practice is still considered criminal, and advocate for greater ownership over a slice of the health care provision pie for women with healthy pregnancies.
But the activism surrounding birth certainly has roots in the research and evidence-based world. There is a growing and well-respected body of evidence that points to the safety of planned home or out-of-hospital birth as well as the benefits of midwife-attended birth, as compared to hospital birth, for women in the U.S. but also globally. The Royal College of Midwives as well as the Royal College of Obstetricians and Gynecologists, both of the U.K., support home birth as an option for women with “uncomplicated pregnancies.”
On the other hand, there is a recent study which shows rising neonatal and maternal mortality rates in The Netherlands, a country where home birth is much more common (and has been for many years) and makes connections between the two. Despite the fact that the study identifies a variety of factors complicit in this rise, some are attacking home birth as an option rather than addressing the myriad reasons for a maternity system which is not protecting the health and lives of its mothers and babies as well as it should. Amy Romano at Science & Sensibility addresses this in her recent post on the issue.
This is about so much more than home birth, however. The United States maternity care system, as we’ve been covering here at RH Reality Check, is dysfunctional in many ways. We spend more money than any other industrialized nation in the world on maternity care ($86 billion per year) and yet our maternal and perinatal mortality rates are not going down (American women have a greater risk of dying from pregnancy-related causes than women in 40 other countries in the world, according to Amnesty International’s recent report on the U.S. maternity care system, Deadly Delivery), African-American women, Native American women and Hispanic women and their newborns are at even greater risk of dying than White women and their newborns in the U.S., and our c-section rate – at 30 percent – is considered “dangerous” by the World Health Organization.
Volleying the safety of planned home birth vs. planned hospital birth back and forth until one, final day sometime in the future, when we’ll uncover the one, irrefutable truth should not be the game plan.
We’ve got a game plan – we’ve got a Blueprint for Action which addresses the many ways in which we can care for the health of all pregnant and birthing women in this country; in which we can save the lives of as many newborns as possible. It involves not a single “truth” but an array of evidence-based choices. After all, for every study that shows the dangers of one option, we’ve got a study to show the safety of that same option or its counterpart. We need to look at the entire platform from health care reform which will help provide greater access to prenatal care for more women to incremental changes like the NIH Consensus Development Conference and ACOG’s statement on the safety of VBACs (vaginal birth after cesarean). We also need to look at legislation like the MOMS for the 21st Century Act which addresses our maternal and newborn mortality rates by looking to implement a broad range of fixes for our maternity care system from federal grants for more – and more racially and ethnically diverse - maternity care providers to consumer education campaigns which put more information and therefore control into the patient’s head and hands when it comes to birth and newborn care.
This is not to discourage future studies on the safety of birth places. As the American College of Nurse-Midwives says:
future research on place of birth in the United States” should “be well-designed and conducted by multidisciplinary teams who are knowledgeable about the complexities inherent in researching the impact of birth setting on perinatal and neonatal outcomes.
It’s just to say that this story is far from over – pregnant and birthing women’s health and lives and the health and lives of their newborns are finally receiving much-deserved attention. We can wade through the politics and evidence and use it all to expand women’s options and save lives.