More Babies Prefer Home Birth

A new study by U.S. researchers questions the safety of giving birth at home, suggesting that more babies die during home births than during hospital deliveries. But Canadian researchers, whose data were extracted and used in the study, say that conclusion is deeply flawed.

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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.

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“Facts are stubborn, but statistics are more pliable.”
Mark Twain 

A new study has been published by the American Journal of Obstetrics and Gynecology.  Predictably, as the prominent organizations of OB/GYN’s have denounced home birth for years, the study determined that home birth posed a significant risk of death for the newborns.  However, having familiarized myself in only a peripheral way in statistical analysis, it was quickly apparent to me that this study was unreliable at best, just from reading a synopsis of it.  How could I know that so quickly?  

The first step in evaluating a study is determining how the data was gathered.  The gold standard of scientific studies is the double-blind prospective study.  This means that participants are randomly assigned to comparative groups, with neither the participant, care-giver nor author knowing which group is which, at the onset of care and evaluating the results going forward.  Of course, this sort of study would be impossible since parents themselves choose place of birth and care giver.  

But, the most unreliable method of studying scientific data is the retrospective study, particularly a meta-analysis.  A retrospective study looks at historical data, data acquired any time in the past, whether recently or decades ago.  A meta-analysis is a whole group of studies which were designed to evaluate different things, but have some factors in common.  Combining these two types of studies consists of compiling all sorts of data from studies large or small, over sometimes a significant period of time.  The design of this type of study is usually intended as a first step in designing a prospective study, culling data to lead investigators to factors worth studying.  These studies should not be used as a means to draw conclusions on their own.  That is contrary to their very design!

In my email, I was forwarded a response to the study in question that has been submitted to the journal which published it, and has been accepted for publication.  This Letter to the Editor details specific areas in which the study is flawed.  

Maternal and newborn outcomes in planned home birth vs planned hospital births: a metaanalysis •

02 July 2010

Joseph R. Wax, F. Lee Lucas, Maryanne Lamont, Michael G. Pinette, Angelina Cartin, Jacquelyn Blackstone
American Journal of Obstetrics & Gynecology

This study is so deeply flawed that it cannot be seen as anything other than politically motivated. Below find the letter that Dr. Patti Janssen and Dr Michael Klein sent to the Am J of Obs and Gyn and which has been accepted for publication.
Michael

To the Editors:
The recent paper comparing maternal and newborn morbidity among births at
home, hospital and in birth centers by Wax et al, reported that babies born
at home more frequently experienced 5 minute Apgar scores below 7.1  The
methodology employed brings into question the validity of this conclusion.
This retrospective study utilized 2006 US Standard Certificates of Live
Birth, used by 19 states in the US. To establish a low obstetrical risk
population, multiple exclusions were applied to the data with the result
that only 36.0% (745, 690/2,073,368) of women in participating states were
included.  Inclusion of only slightly more than one third of the potentially
eligible population raises questions about the ability of birth certificates
to identify women at low risk and consequently the generalizability of study
findings.
Secondly, ascertainment of the type of birth attendant is missing for 4801
women or 0.6% of the sample.  It is possible that at least some of these
births were unattended.  If this indeed the case, then these births, which
would be expected to have high rates of suboptimal outcomes, might be
over-represented in the home birth group, where the attendants are less
likely to arrive on time for a precipitous birth.  In addition, some women
may have deliberately chosen to have an unattended birth and these would of
course take place outside of a hospital or birth centre.
Since only 75% of the births studies were recorded as attended by a
physician or midwife, fully one quarter may have been unplanned home births.
Unplanned home births are well known to be at higher risk for adverse
outcomes.
Lastly, the authors acknowledge that births for which complications
necessitated transfer to hospital are attributed to hospital rather than to
home or birth centre births.  In contrast to the above biases, this bias
would favor home births.  They also acknowledge that perinatal mortality is
not measured, which eliminates deaths occurring during labour.
In view of these serous flaws, the statement that this study provides a
“robust evaluation of maternal and newborn outcomes that is generalizable
and reflects actual practice” cannot be supported.  Without internal
validity, placed in question by missing data and the inability to attribute
births to planned place of birth, the issue of external validity or
generalizability is irrelevant.  Recent studies in Canada2, 3 and the
Netherlands4 have used population-based perinatal databases with mandated
participation by midwives and documentation of intended place of birth and
attendant, as well as relevant outcomes including intrapartum fetal death.
American studies of place of birth must meet this standard in order to draw
valid conclusions and allow international comparisons.

1.                  Wax J, Pinette M, Cartin A, Blackstone D. Maternal and
newborn morbidity by birth facility among selected United States 2006
low-risk births. Am J Obstet Gynecol. 2009;202(2): 152e151-e155.
2.                  Janssen P, Saxell L, Page L, Klein M, LIston R, Lee S.
Outcomes of planned home birth with registered midwife versus planned
hospital birth with midwife or physician. Can Med Assoc J. 2009;181:277- 383.
3.                  Hutton K, Reitsma A, Kaufman K. Outcomes associated with
planned home and planned hospital births in low-risk women attended by
midwives in Ontario, Canada, 2003-2006: A retrospective cohort study. BIRTH.
2009;36(3):180- 189.
4.                  de Jonge A, van der Goes B, Ravelli A, et al. Perinatal
mortality and morbidity in a nationalwide cohort of 529, 688 low-risk
planned home and hospital births. BJOG. 2009;116:1177- 1184.

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This Pregnancy: The First Twenty Weeks 
Between Maddie’s birth and this pregnancy, I learned a lot. I’m a childbirth teacher and have worked as a doula. I’ve read piles on childbirth and have gone through three different professional training workshops. I attended 2 homebirths as a doula, and 4 hospital births. By the time I got pregnant with this baby, there was no doubt I was having a homebirth. The idea of going back to the hospital to have a baby seemed too risky to me. 

I hired the midwife who was present at the two homebirths I attended. She was very hands-off at those births and I was extremely impressed by her. I knew there was no other attendant I could feel at ease with. I told her that I’d be calling her late in labor, and that I’d rather her not make it on time than get there too early and risk “performance anxiety” slowing my labor. As the pregnancy went on, I realized that deep down, I didn’t expect to call her at all.

In my first 20 weeks, I had two prenatal visits. I had no blood work, no gestational diabetes test, no genetic screening, no ultrasounds, not even listening to the baby with a Doppler (which exposes the baby to ultrasound). After 20 weeks I was able to find the heartbeat myself with a fetoscope. I would not be having a group B strep test, checking my fluid levels with ultrasound, fretting about the baby’s size. I was just enjoying my pregnancy and it was truly wonderful.

Unassisted Birth: My Psychological & Emotional Journey
When I was late in my pregnancy with Maddie, around 37 weeks I believe, the midwife said that they liked to induce at 41 weeks. This was totally unacceptable to me. I don’t believe in evicting babies before they’re ready based on a date that should really be +/- at least 2 weeks. The risks associated with induction were beyond what I was willing to accept without a true medical reason. Needless to say, I started to feel a lot of stress over this impending fight, were I to go past 41 weeks (I actually went to 41 weeks, 4 days). My precious husband said, “Don’t worry about it-if they try to force an induction we’ll just stay home and do it ourselves.

And there, the idea of unassisted homebirth was born. It’s interesting to me that so many women who want homebirths-assisted or unassisted-are thwarted by scared spouses, and the whole idea of unassisted birth came through my husband. Staying home without a midwife had never even occurred to me. But suddenly it became our back up plan, and I started to think about how great an experience it would be.

In the end, the midwives didn’t pressure me into an induction and I stuck with my hospital plan. When Maddie was just a baby, I got a copy of Unassisted Childbirth by Laura Shanley from the library. It was so fascinating. Her way of giving birth felt very right (I later read The Power of Pleasurable Childbirth by Laurie Morgan, which really appealed to my practical nature).

Around 18 weeks I realized I wasn’t going to call the midwife, and knew I needed to talk to her. I gave myself a couple of weeks to think it over, then called her around 20 weeks. She was very supportive of my decision, willing to be there for me if I needed her. 

I continued my pregnancy with no problems, and no stress. Once I decided officially on an unassisted birth, it’s like a weight was lifted from my shoulders. I knew it was right for me. I told very few people in my real life, because I didn’t want to deal with negativity, and I also didn’t want to cause unnecessary stress for my family. Most people in our culture don’t really believe birth is safe, and I didn’t want people worrying about the baby and me. I wasn’t worried-why should they be?

The Birth of Grace Alexandra
I’d been having contractions for weeks, real ones as well as Braxton-Hicks. On the night of September 9, I tried to go to bed around 9. Contractions were 15-20 minutes apart, and I wanted to sleep between them. They were really strong, and I’d wake up right at the peak and unable to stay on top of them. Around 10:30 I tried propping myself up in bed because lying down was making them worse, but even with that the waking up at the peak was too much. Around 11:15 I went out in the living room with Chad. We put in a Friends DVD and hung out for about 45 minutes. As soon as I was in the living room, contractions jumped to 5-7 minutes apart.

Around midnight I really wanted to get in the birth pool, but was thinking it was really too early. I decided I didn’t care-the water was calling me. Chad tried to convince me just to take a bath in the tub first, to see if it really was labor this time. I said no. I knew this was it. He filled the tub and I got in. It was heavenly!

We put Friends on the computer and we actually watched it right up until transition. The water got my contractions closer together, not further apart. They were 3-4 minutes apart almost as soon as I got in, then 2-3 minutes. The DVD player shut down and I told Chad to leave it off. I remember sitting in the warm water, with the windows open. It felt so good, and I could hear the crickets chirping outside, and thinking, “This is the way to do this. I don’t want to be anywhere else.” 

Transition was intense and painful but less confusing and scary than it was with Maddie, by far. I never felt out of it or confused like I did with her birth. Soon it felt better to bear down than to relax, and Chad thought I still hadn’t gone through transition but I was already pushing! He was blown away to realize how quickly things were going-he’d hardly had to do any work yet.

My water hadn’t broken yet, after quite a few pushing contractions, but I could feel her head right there. I allowed the overwhelming urge to take over at first, then forced myself to breathe through and slow down, with Chad’s help. I felt her head trying to come out but the bag of waters was still there. I thought, I wonder if my short, bitten nail could break the thing. I touched it, barely, and it popped. Then I could feel hair and that was all the encouragement I needed. I wish I could describe what the rest of the birth was like but I don’t really have the words. To know that we were doing this, totally our way and that it was going so quickly and smoothly, was just really amazing. Chad and I just looked at each other in awe of what was happening. We felt completely connected to each other, to the baby, and to the entire process as it unfolded exactly the way it was meant to.

Chad couldn’t believe how far along I was already. He thought we’d have hours left. I pushed, gently, through crowning, which took several contractions. I did my own perineal support and could tell exactly where I needed to put pressure to keep from tearing. Crowning was intense but so cool! I could feel the baby trying to help me, pushing with her feet and trying to get out too. Her head and body came out in one contraction, and Chad said “Reach down!” I caught her myself, and pulled her up to me. The cord was around her neck but she was already crying and breathing just fine. I unwound it, and she nursed within about 3 minutes. It was so incredible! 

I thought the whole pregnancy that I was having a boy, so it was a little surprising to find out she was a girl! But I knew before she was even out-I changed from “he” to “she” unconsciously-I remember saying to Chad, “The cord is around her neck.” 

The water was a little cool so we got out pretty soon. I sat down on some towels on the floor, and plop! Out came the placenta. That was easy! I bled less than I did with Maddie and was much less sore. I didn’t tear, except for a little skidmark I couldn’t even see (but could feel when I used the bathroom for about the first day). She was born around 3:23 am, after just about 4 hours of active labor. We didn’t check the time right away but that’s pretty close. We called all the people who wanted late-night calls, and Chad’s mom came over for a little while to meet her. She went home and we went to bed for a couple of hours. It was so nice to be finished with birthing, take a shower in my own shower, then cuddle up in our own bed. Maddie slept through the whole thing, and in the morning she was SO excited to meet her little sister!

We had lots of visitors our first day with her, and that was nice too-no cooking and everybody brought me stuff! We weighed her Sunday afternoon, and she was 8 pounds, 1 ounce. We also finally came up with her name, Grace Alexandra. My recovery with Maddie amazed everyone I knew, but this recovery was insanely easy. I was out shopping with Chad and my 2 girls on Tuesday (she was born Sunday morning). I wasn’t sore after the first day postpartum, and my milk came in in under two days. That took 5-6 days with Maddie, and I’m 100% convinced it was the interruption in our home life that caused the delay.


Having just Chad and me present for the birth is the best thing we’ve ever done. I wasn’t at all afraid-I just knew everything was fine. We were the only people there when she was conceived, and it felt absolutely 100% right that we were the only people there when she was born. I was able to listen to my body completely, without anyone to depend on but myself and Chad. Chad was wonderful-he helped me remember not to push too hard, and he was my anchor during transition and pushing both physically and emotionally. Her birth was intense, sometimes painful, very hard work…but definitely one of the most incredible things I’ve ever experienced.

{If you’d like to share your own home birth story, please use the form at right to submit it.}