Study Shows Having Baby at Home Is Safe


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Original study

Original WebMD article

My version of the WebMD article

Original WebMD article with my comments

My general web page about homebirth safety

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Here's the original study that motivated the article:

Outcomes of planned home births with certified professional midwives: large prospective study in North America
Kenneth C Johnson, senior epidemiologist, Betty-Anne Daviss, project manager
BMJ  2005;330:1416 (18 June), doi:10.1136/bmj.330.7505.1416

Conclusions: Planned home birth for low risk women in North America using certified professional midwives was associated with lower rates of medical intervention but similar intrapartum and neonatal mortality to that of low risk hospital births in the United States. [NOTE - CPMs are equivalent to Licensed Midwives in some states.]

The BMJ has made the full text of this article available free to the public.
 
 

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Many people who are quoted in the press wish they had an opportunity to edit the article before publication.  Well, through the wonderful magic of the Internet, I'm giving myself that opportunity here.  Here's my edited version of the article:
 

Study Shows Having Baby at Home Is Safe


Pediatrician Says Itís Obvious Why Home is Safer

By Salynn Boyles, edited by Ronnie Falcao, LM MS
on Sunday, June 19, 2005

June 19, 2005 - A new study has confirmed that homebirth is as safe as or safer than hospital births for low-risk women and their babies.  The nation's largest organization of obstetricians has long been opposed to homebirth, but obstetrics is also considered the least evidence-based branch of modern medicine.

"Home births are common in a number of European countries, and these countries also have very low rates of (birth-related) infant mortality," epidemiologist and lead researcher Kenneth C. Johnson, PhD, tells WebMD. "In North America, and especially in the United States, there has been much less acceptance of home births by the medical communities."

Researchers compared results from roughly 5,400 planned home births within the U.S. and Canada attended by midwives with hospital births during the same period.

The death rate among babies born at home was similar to low-risk hospital births. However, the rate of medical interventions, such as epidurals, episiotomies, and cesarean deliveries, was much lower among home births.  In fact, the rate of epidurals and cesarean deliveries at home is 0%.  Many homebirth midwives have episiotomy rates close to 0% and suture rates around 5-10%, so that most mothers recover very quickly from the birth and can breastfeed comfortably in a variety of positions.  Breastfeeding reduces infant mortality in the first year by 20%, so all birthing practices should consider the importance of supporting breastfeeding as much as possible.

Like their hospital-based counterparts, homebirth midwives provide ongoing risk assessment and surveillance of the mother and the fetus throughout labor and the hours immediately after the birth.  They carry state-of-the art fetal monitoring and resuscitation equipment such as portable continuous electronic fetal monitoring devices and mechanical suction and ventilation devices.  Their specialized skills enable them to facilitate easier labors and to improve outcomes by working to support the natural process and interfere as little as possible.  When necessary, midwives accompany their clients to the hospital for medical interventions as indicated, or they provide emergency interventions in the home to control postpartum hemorrhage or resuscitate a newborn.

The study is published in the June 19 issue of the British Medical Journal.

A Mom's Story

Cupertino, Calif., mom Jennifer Hess, 31, chose to have her second son, Kevin, at home last year based on her experience during the birth of her first son, Gregory, in 2001.

The events leading up to Gregory's hospital birth were uneventful, but as soon as he was born he was whisked away by nurses because of an unspecified breathing difficulty.

For the next two hours, Hess says, she was told nothing about her baby's condition and she imagined the worst.

"I had torn (during delivery) and they didn't sew me up right away," she tells WebMD. "And they sent my husband to the nursery with the baby, which is where he should have been. So I had no information for hours. I would ask the nurses if my baby was OK and they wouldn't tell me. They said I should wait and talk to my husband. Naturally, I was pretty distraught."

To make matters worse, just minutes after she was finally reunited with her baby they whisked him away again so that the doctor could perform routine tests.

"My experience with the birth of my first son wasn't exactly the best, so it's fair to say that I was very open to the idea of a home birth," she says.

Night and Day

Hess says the difference between her first delivery and her second with home-birth midwife Ronnie Falcao was like night and day.

"In the hospital they would examine me when it was convenient for them, even if I was in the middle of a contraction," she says. "But Ronnie was there to offer support and do things on my schedule. It was the best thing ever to have my baby in my environment and not some strange setting."

Falcao, who is a Licensed Midwife, has attended about 100 home births in and around Silicon Valley. She tells WebMD that it has become more difficult over the past few years for women planning homebirths to choose the physicians who would provide medical care for them in the hospital if needed. She says insurance companies in California have adopted a policy of terminating the malpractice insurance of doctors who back up home-birth midwives, thus limiting the options of birthing women in California.

She says that her outcomes are excellent, with a 0% mortality rate and with no permanent birth traumas.  Her cesarean rate is less than 10%, despite having a clientele that is age biased towards the late 30's.  Her episiotomy rate is 0%, and her suture rate is less than 5%.

She estimates that just under a third of her first-time moms will end up giving birth in a hospital due to the slower progress that is typical with first babies.  Most women who have already had babies and are planning a homebirth will indeed give birth at home; these experienced mothers often have labors that are just a few hours because of the supportive environment of laboring at home.

In just a very few cases, there have been situations where the mother has developed a fever in labor or the baby is not tolerating the stresses of labor very well, so it was necessary to go to the hospital for medical care.

A total of 12% of the women who planned home births in the newly published study ended up being transferred to hospitals due to complications.

Most Midwife Births in Hospitals

According to CDC figures, the number of births attended by midwives increased steadily between 1975 and 2002, rising from just under 1% in the mid-'70s to 8%.

But the vast majority of these births were attended by nurse midwives in hospitals or birthing centers. There are no good figures on home births in the United States, but in a 2000 report the CDC estimated that the numbers are growing.

The American College of Obstetricians and Gynecologists (ACOG) represents more than 46,000 women's health care physicians. The group opposes home birth on principle, as they have for the last hundred years.  When asked to provide research evidence supporting their position, ACOG has only been able to cite questionable studies such as the Pang study and the Australian outback study.  It is not surprising that obstetricians in the United States are not supportive of healthcare providers who are their rivals in the birthing business, just as individual hospitals compete to attract birthing women.  In other countries, it is understood that midwives are specialists in normal birth, and obstetricians are specialists in pregnancy and birth complications, so there is no rivalry.  For those interested in the economics of this situation, there is an excellent analysis of the $15 billion annual waste of mis-using surgical specialists for normal birth in the United States.

"Labor and delivery, while a physiologic process, clearly presents potential hazards to both mother and fetus before and after birth," the ACOG position statement on home birth states. "These hazards require standards of safety that are provided in the hospital setting and cannot be matched in the home situation."  ACOG is probably unaware that the portable equipment and training at a homebirth are equivalent to a birth center and that both can equal that of a typical community hospital.  ACOG also glosses over the risks inherent in being admitted to the hospital for even the simplest procedure.  In particular, hospital-acquired infections can be devastating to a newborn's immature immune system.

The benefit of laboring in the hospital is that there is immediate access to an operating room.  However, the operating room itself is useless if there is no obstetrician in the hospital.  Most doctors remain at their own homes while women are laboring, and they only arrive at the hospital when it is clear that they are needed.  Guidelines for hospitals offering maternity care require that they be able to perform a cesarean within 30 minutes of the decision that one is needed.  Homebirth families choose the same approach, laboring at home as long as possible, and only going to the hospital when it is clearly necessary.  Ideally, laboring at home as long as it is clearly safe will result in the baby's being born in the safer environment of the home.

Other organizations with less conflict of interest are actively supportive of homebirth. In contrast to the ACOG position, the American Public Health Association passed a resolution in 2001 to increase access to out-of-hospital birth attended by credentialed direct-entry midwives.  The APHA based their decision on the weight of evidence about home birth demonstrated in the numerous home birth studies carried out with better methodologies than were used in the Pang study.

But Pediatrician Says Itís Tough to Be Prepared for Emergencies at Home

Pediatrician Concerned About Home Births

Pediatricians who are concerned tend to focus on the 2002 study by Seattle pediatrician Jenny W. Pang, MD, MPH, and colleagues from the Washington School of Public Health.  They analyzed the outcomes of unplanned homebirths or planned unassisted homebirths and found that the outcomes are not as good as for hospital births or for planned homebirths with a professional birth assistant. Henci Goer's excellent critique of the Pang study goes into detail about the flaws of lumping unplanned homebirths or unassisted homebirths in with planned homebirths with a professional birth assistant.

Pang tells WebMD she believes homebirth can never be as safe as hospital birth, regardless of the birth attendant. "Whether you are talking about a physician, a nurse-midwife, or a [non-nurse] midwife, the thing that matters most is how much experience they have," she says. "My reservations about home births have less to do with who is in charge than they do with location."  Pang was unable to make up her mind as to whether she believes homebirths are unsafe because of the experience of the birth attendant or the location. Pang continued, "You can't possibly be set up for all the emergencies that may arise in a home setting." Dr. Pang seems unaware the many homebirth midwives carry suctioning and resuscitation equipment that is equivalent to an intensive care nursery, with the exception of intubation  In some locations, such as in Mountain View, CA, every local fire station has a paramedic who is trained and equipped to intubate newborns, and they can be at most homes within the same time frame it takes the pediatrics team in the hospital to get to a labor and delivery room when there is surprise meconium and a nonvigorous baby.  Pang also discounts the risks inherent in being admitted to the hospital.

SOURCES: Johnson, K.C. British Medical Journal, June 18, 2005; vol 330: pp 1416-1419. Kenneth C. Johnson, PhD, epidemiologist, Surveillance and Risk Assessment Division, Centre for Chronic Disease Prevention and Control, Public Health Agency of Canada, Ottawa, Ontario. Jenny Pang, MD, MPH, pediatrician, Seattle. Ronnie Falcao, LM, MS, homebirth midwife, Mountain View, Calif. Jennifer Hess, mother of two, Cupertino, Calif.
 
 


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Here are my comments about the article:

Study Shows Having Baby at Home Is Safe


But Pediatrician Says Itís Tough to Be Prepared for Emergencies at Home

By Salynn Boyles
WebMD Medical News  Reviewed By Michael  Smith, MD
on Friday, June 17, 2005
More From WebMD

June 17, 2005 - Planned home births are considered unsafe by the nation's largest organization of obstetricians, but a new study shows them to be as safe as hospital births for low-risk women and their babies.

"Home births are common in a number of European countries, and these countries also have very low rates of (birth-related) infant mortality," epidemiologist and lead researcher Kenneth C. Johnson, PhD, tells WebMD. "In North America, and especially in the United States, there has been much less acceptance of home births by the medical communities."

Researchers compared results from roughly 5,400 planned home births within the U.S. and Canada attended by non-nurse midwives with hospital births during the same period. [It's funny that in the United States, midwives are expected to be nurses first, which is a holdover from the 70's when midwifery training in the United States sprang up again out of the nursing schools.  In most countries, midwives are specialists in midwifery and are trained in midwifery, including the components of a nursing curriculum that are relevant to midwifery.  Obstetricians and pediatricians are also not nurses, yet they are not described as non-nurse OBs or non-nurse pediatricians; I hope they are also trained in the components of a nursing curriculum that are relevant to their work.]

The death rate among babies born at home was similar to low-risk hospital births. However, the rate of medical interventions, such as epidurals, episiotomies, and cesarean deliveries, was much lower among home births.  [Epidurals and cesareans are not done at home by any kind of provider, and they are outside the scope of midwifery.  The medical intervention that midwives routinely perform at home is limited to fetal monitoring during labor, either with fetoscopes, handheld Dopplers, or portable Electronic Fetal Monitors such as Huntleigh's Fetal Assist.  The medical interventions that midwives perform at home in response to complications include administering medications such as pitocin for postpartum hemorrhage, suctioning and resuscitating newborns, and suturing perineal tears or very-rare episiotomies.  Midwifery encompasses a great number of non-medical interventions: facilitating an easier labor and birth by noticing and working to change a posterior presentation; assisting the laboring woman with comfort measures such as laboring in warm water; suggesting position changes to facilitate optimal fetal oxygenation, labor progress and productive pushing; and creating an environment that is supportive of initial breastfeeding and bonding.]

The study is published in the June 19 issue of the British Medical Journal.

A Mom's Story

Cupertino, Calif., mom Jennifer Hess, 31, chose to have her second son, Kevin, at home last year based on her experience during the birth of her first son, Gregory, in 2001.

The events leading up to Gregory's hospital birth were uneventful, but as soon as he was born he was whisked away by nurses because of an unspecified breathing difficulty.

For the next two hours, Hess says, she was told nothing about her baby's condition and she imagined the worst.

"I had torn (during delivery) and they didn't sew me up right away," she tells WebMD. "And they sent my husband to the nursery with the baby, which is where he should have been. So I had no information for hours. I would ask the nurses if my baby was OK and they wouldn't tell me. They said I should wait and talk to my husband. Naturally, I was pretty distraught."

To make matters worse, just minutes after she was finally reunited with her baby they whisked him away again so that the doctor could perform routine tests.

"My experience with the birth of my first son wasn't exactly the best, so it's fair to say that I was very open to the idea of a home birth," she says.

Night and Day

Hess says the difference between her first delivery and her second with home-birth midwife Ronnie Falcao was like night and day.

"In the hospital they would examine me when it was convenient for them, even if I was in the middle of a contraction," she says. "But Ronnie was there to offer support and do things on my schedule. It was the best thing ever to have my baby in my environment and not some strange setting."

Falcao, who is not a nurse, has attended at about 100 home births in and around Silicon Valley. [Again, it's pointed out that I am not a nurse.  Of course I'm not a nurse; why would a nurse be attending births?  I'm a midwife.]  She tells WebMD that it has become more difficult over the past few years to find partner physicians to work with her if the mom ends up needing medical care. [This could be open to the interpretation that homebirth clients have not been able to access the medical care they needed, which is not true.  They just don't have the luxury of pre-selecting their backup physicians without hiding their intentions to birth at home.]  She says insurance companies in California have adopted a policy of terminating the malpractice insurance of doctors who back up home-birth midwives.

She estimates that just under a third of her first-time moms will end up giving birth in a hospital due to complications, but the rate is much lower among women who have already had babies.  [These complications are typically non-emergency complications, such as a stalled labor.  Very rarely, there has been a maternal fever or fetal distress, which required prompt medical care in a hospital setting.]

A total of 12% of the women who planned home births in the newly published study ended up being transferred to hospitals due to complications.

Most Midwife Births in Hospitals

According to CDC figures, the number of births attended by midwives increased steadily between 1975 and 2002, rising from just under 1% in the mid-'70s to 8%.

But the vast majority of these births were attended by nurse midwives in hospitals or birthing centers. There are no good figures on home births in the United States, but in a 2000 report the CDC estimated that the numbers are growing.

The American College of Obstetricians and Gynecologists (ACOG) represents more than 46,000 women's health care physicians. The group opposes home birth. [When asked to provide research evidence supporting their position, ACOG has only been able to cite questionable studies such as the Pang study and the Australian outback study.  In contrast to the ACOG position, the American Public Health Association passed a resolution in 2001 to increase access to out-of-hospital birth attended by credentialed direct-entry midwives.  The APHA based their decision on the weight of evidence about home birth demonstrated in the home birth studies carried out with better methodologies than were used in the Washington study.]

"Labor and delivery, while a physiologic process, clearly presents potential hazards to both mother and fetus before and after birth," the ACOG position statement on home birth states. "These hazards require standards of safety that are provided in the hospital setting and cannot be matched in the home situation." [ACOG is probably unaware that the portable equipment and training at a homebirth are equivalent to a birth center and that both can equal that of a typical community hospital.  ACOG also glosses over the risks inherent in being admitted to the hospital for even the simplest procedure.  In particular, hospital-acquired infections can be devastating to a newborn's immature immune system.  These risks are much greater than the benefit of immediate access to cesarean surgery that is available only in the hospital.]

But Pediatrician Says Itís Tough to Be Prepared for Emergencies at Home

Pediatrician Concerned About Home Births

In a 2002 study, Seattle pediatrician Jenny W. Pang, MD, MPH, and colleagues from the Washington School of Public Health reported that babies delivered at home have nearly twice the risk of dying shortly after birth as those born in the hospital. The researchers reviewed more than 7,500 home births and 14,000 hospital births in Washington between 1989 and 1996. [Henci Goer's excellent critique of the Pang study points out that it included unplanned homebirths or planned unassisted homebirths.]

Pang tells WebMD that the risk was still very small, with just 0.33% of babies born at home dying, compared to 0.17% of hospital-born babies. And she says she does not believe the findings reflect a difference in competence between attending physicians and midwives.

"Whether you are talking about a physician, a nurse-midwife, or a [non-nurse] midwife, the thing that matters most is how much experience they have," she says. "My reservations about home births have less to do with who is in charge than they do with location. You can't possibly be set up for all the emergencies that may arise in a home setting." [I think Dr. Pang would be surprised at the number of emergencies that we actually are equipped to handle at home.  I carry suctioning and resuscitation equipment that is equivalent to an intensive care nursery, with the exception of intubation; here in Mountain View, CA, every local fire station has a paramedic who is trained and equipped to intubate newborns, and they can be at most homes within the same time frame it takes the pediatrics team in the hospital to get to a labor and delivery room when there is surprise meconium and a nonvigorous baby.]

SOURCES: Johnson, K.C. British Medical Journal, June 18, 2005; vol 330: pp 1416-1419. Kenneth C. Johnson, PhD, epidemiologist, Surveillance and Risk Assessment Division, Centre for Chronic Disease Prevention and Control, Public Health Agency of Canada, Ottawa, Ontario. Jenny Pang, MD, MPH, pediatrician, Seattle. Ronnie Falcao, licensed midwife, Mountain View, Calif. Jennifer Hess, mother of two, Cupertino, Calif.

The article as originally published on WebMD.

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This was written by Ronnie Falcao, LM MS, a Licensed Midwife in Mountain View, California

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