ACOG Practice Bulletin: Homebirth

Take away quote:

… Women inquiring about planned home birth should be informed of its risks and benefits based on recent evidence. Specifically, they should be informed that although the absolute risk may be low, planned home birth is associated with a twofold to threefold increased risk of neonatal death when compared with planned hospital birth. Importantly, women should be informed that the appropriate selection of candidates for home birth; the availability of a certified nurse–midwife, certified midwife, or physician practicing within an integrated and regulated health system; ready access to consultation; and assurance of safe and timely transport to nearby hospitals are critical to reducing perinatal mortality rates and achieving favorable home birth outcomes.

Outcomes of planned home births in Washington State

Results: 

Infants of planned home deliveries were at increased risk of neonatal death (adjusted relative risk [RR] 1.99, 95% confidence interval [CI] 1.06, 3.73), and Apgar score no higher than 3 at 5 minutes (RR 2.31, 95% CI 1.29, 4.16). These same relationships remained when the analysis was restricted to pregnancies of at least 37 weeks’ gestation. Among nulliparous women only, these deliveries also were associated with an increased risk of prolonged labor (RR 1.73, 95% CI 1.28, 2.34) and postpartum bleeding (RR 2.76, 95% CI 1.74, 4.36).

Underwater Birth: Missing the Evidence or Missing the Point

The gist of the article wrapped up in one quote:

If we are to feel confident regarding the safety of underwater birth for the neonate, we must be confident that a sufficient number of cases have been scientifically scrutinized in a rigorous fashion and that these cases demonstrate a reasonably low probability of harm as compared with the current standard of birth above water. Furthermore, if there is possible case report evidence of harm without demonstrable improvement in outcomes, we must question the rationale for continuing the practice of offering underwater birth. We found case reports of infants with pneumonias, hyponatremic seizures, Pseudomonas infections, and multiple freshwater drownings attributed to underwater birth. Have these reports been missed by others or simply ignored? Of importance, none of the reports we reviewed made any claim of underwater birth being better for the infant.

Additional Reading:

Waterbirth: A Near Drowning Experience

Underwater Births

Water Birth — Is it Safe

Outcomes of Planned Home Birth with Registered Midwife Versus Planned Hospital Birth with Midwife or Physician

Patients were divided into three groups, homebirth, hospital birth with a midwife and hospital birth with a doctor. Risk levels were matched by excluding anyone from either hospital group if they would not meet the eligibility criteria for homebirth.

Key findings:

The rate of perinatal death per 1000 births was very low and comparable in all 3 groups: it was 0.35 (95% confidence interval [CI] 0.00–1.03) among the planned home births, 0.57 (95% CI 0.00–1.43) among the planned hospital births attended by a midwife and 0.64 (95% CI 0.00–1.56) among the planned hospital births attended by a physician. There were no deaths between 8 and 28 days of life.

This is great news for low-risk women who want homebirths. Unfortunately, here in Oregon, licensed midwives are not required to have anywhere near the training held by registered Canadian midwives, and the risk-out criteria is so lax, it would be laughable if it weren’t so dangerous. What happens when you compare the Canadian stats from this study to stats from the United States? You get this:

For more information, read here.

Perinatal Mortality and Severe Morbidity in Low and High Risk Term Pregnancies in the Netherlands: Prospective Cohort Study

In the study, the researchers found that infants of LOW RISK pregnant women whose labor started in primary care under the supervision of a midwife in the Netherlands had a higher risk of delivery related perinatal death and the same risk of admission to the NICU compared with infants of HIGH RISK pregnant women whose labor started in secondary care under the supervision of an obstetrician.

According to the World Bank, the Netherlands also has one of the highest maternal mortality rates in Europe:

Johnson and Daviss: Outcomes of Planned Homebirths With Certified Professional Midwives

When it was discovered that they had compared homebirth numbers from the year 2000 to hospital numbers from as far back as thirty years (instead of the readily available hospital numbers from the year 2000), Johnson and Daviss re-ran the numbers using the stats from the correct year. The found that the real neonatal death rate in the hospital in 2000 of 0.9/1000, which posed a serious problem for their conclusion; their study reported a neonatal death rate at homebirth of 2.6/1000 — approximately three times the hospital death rate of 0.9/1000.  In order to justify their original conclusion, they removed deaths as a result of congenital birth defects from the homebirth group, but did not do the same for the hospital group.

Further reading:

http://skepticalob.blogspot.com/2011/04/being-published-doesnt-make-it-true.html

http://homebirthdebate.blogspot.com/2007/12/johnson-and-daviss-acknowledge-validity.html

http://homebirthdebate.blogspot.com/search/label/Johnson%20and%20Daviss

For more information, read here.

For more information, read here.

Bottom line: The perinatal death rate for licensed midwives in Colorado is double the perinatal death rate for hospital births in the entire state, which includes all pregnancy complications and premature births.

As Dr. Amy Tueter explains,

The data is conveniently broken down by type of death and place of death. For example, there were three intrapartum deaths for an intrapartum death rate of 3.8/1000, more than TEN TIMES HIGHER than the intrapartum death rate commonly experienced in hospitals. There were 4 neonatal deaths for a neonatal death rate of 5/1000. That’s TEN TIMES HIGHER than the national neonatal mortality rate for low risk hospital birth with a CNM. On hundred women were transferred in labor or after delivery for a transfer rate of 12.5%. The neonatal death rate in the transfer group was 50/1000, an appalling neonatal death rate ONE HUNDRED TIMES HIGHER than that expected in a group of low risk women.

Other links on the Colorado homebirth situation:

http://skepticalob.blogspot.com/2009/12/you-might-expect-that-such-appalling.html

http://skepticalob.blogspot.com/2011/10/how-many-babies-died-at-hands-of.html