Extremely important new paper on safety v birth setting

Parentberries
1

As the board has been discussing some very interesting and very important topics re: birth practices and birth settings recently, I wanted to make a separate thread just for this new paper-- it’s that crucial.

The CDC (in the US, the main public health agency) has long collected very basic outcomes data based on place of birth. These data include: 1) live births versus intrapartum [in-labor] deaths; 2) 1-minute and 5-minute APGARs-- an assessment of how well a baby is breathing, how its heart is beating, and its neurological function; 3) subsequent NICU admission and NICU diagnoses, including hypoxic seizures. ‘Hypoxic seizures’ means those resulting from prolonged oxygen deprivation to the baby’s brain, usually from cord and/or placental problems during the birth. Fetal monitors are meant to capture the worrisome trends in heartbeat that correlate with hypoxia.

OK, enough introduction. Finally a group of researchers had enough time to cull through ALL US births-- every single one-- since 2007, and separate them into four groups: 1) Hospital birth with a physician; 2) hospital birth with a Nurse-Midwife; 3) Freestanding Birth Center birth [could be Nurse-Midwife or lay midwife]; 4) homebirth with a midwife (nearly always lay midwife, AKA CPM/LM). This is over 14 million births!!! You can’t get better data than this!!! Also, only singletons were considered, and only full-term births (>37 weeks gestation).

Two things to keep in mind:

– the data ONLY captures where the baby was actually [name]BORN[/name], not where labor started or who managed it initially. Since transfers between birth settings only go one way-- home/birth center -> hospital-- any complication that occurred at home, such a prolonged oxygen deprivation due to mismanaged labor or inability to intervene, but which was TRANSFERRED to the hospital and delivered at the hospital, counts in the “hospital” group. This ALWAYs serves to UNDERESTIMATE the inherent risk of homebirth/ birth center birth since a certain %age of their bad outcomes get counted in the hospital group.

– the Hospital MD group of women includes all high-risk women and all high-risk babies. The Hospital Midwife group is low-risk women only. Since a labor complication can be transferred to MD care immediately within a hospital, simply by shouting down the hall, the Hospital Midwife patient group to me represents the best, most pure outcome data for healthy, low-risk women, and shows how beautifully a two-tiered system can work. Because of the fact that all high-risk, complicated women and babies are always managed by MDs, the MD data will always look “worse” than the Hospital Midwife data.

OK, the results:

“Relative risk” = %age increase in your chance of developing the outcome. A RR of 2 = 200% increase, or double, your chance of developing the thing in question.

Risk of 5 minute APGAR of [name]ZERO[/name] [baby near-death]

Hospital MD: 0.16% of all births; RR 1 [since hospital MDs delivered over 12 million of the babies, they were used as the reference group]
Hospital Midwife: 0.09% of all births, RR 0.55 [only HALF the risk]

Birth Center Midwife: 0.55%, or RR of 3.56 (356% increased risk)
HOMEBIRTH MIDWIFE: 1.63% or RR of 10.55 (1,055% increased risk!!!)

[name]Even[/name] scarier: when you disaggregate the home birth data into first-time mothers versus mothers with at least one birth: the first-time mothers had an increased risk of 5-min APGAR of 0 of 14.55 (1,455% increase). 1+ previous births meant you fared slightly better, with a RR of 9.5, so only a ten-fold increase.

Risk of neonatal hypoxic seizures from prolonged oxygen deprivation

Birth center midwife: RR 1.88 (188% increase)
Homebirth midwife: RR 3.80 (380% increase in severe neurological dysfunction, though not death)

Here is the paper, though unfortunately without an institutional login or subscription you can only read the abstract:

http://www.ajog.org/article/S0002-9378(13)00641-8/abstract

This is raw data guys, straight from the CDC, no spin. If you suspect I’m anti-homebirth you’re right, but only because I look at the data and the data tells me it kills babies unnecessarily.

If you want a midwife-attended birth, compare the outcomes for hospital midwives (who are competent trained professionals) to homebirths midwives (who are not). [name]Both[/name] supposedly represent the same pool of low-risk, healthy women patients, but the homebirth outcomes led to TWENTY times more dead babies than the hospital midwives.

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Statistics! <3

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Thank you for sharing! As someone who is extremely skeptical of western medicine and strongly dislikes hospitals, I still chose to have a hospital birth with a CNM. I did my research, looked into all of the possible treatments and interventions they might perform, and knew what I felt was more for their convenience than my own/my baby’s safety.

Giving birth is something totally natural and doesn’t need to be a medical procedure, but if you think about how many infant deaths occurred before hospital births were commonplace, it makes sense to give birth where monitoring can be done and intervention is available if needed.

I was really happy with my labor and delivery, and while before this I considered having a home birth for my next pregnancies, I would gladly choose a hospital birth with a CNM again.

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Thanks [name]Blade[/name]! Great info that makes sense!

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Thanks, [name]Blade[/name]! What an incredible amount of births to comb through.

I do wish that there was a way to distinguish birth center/homebirths performed with a certified nurse-midwife as opposed to lay midwives. I’m sure they’re still higher than hospital births, but I’d like to know those numbers. I understand why that would be nearly impossible, but it would help me to make a more informed decision for my next birth :slight_smile:

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Thanks for the information, [name]Blade[/name]. Personally, I’m a fan of natural deliveries and pain-free labour (in theory, anyway. Maybe I’ll change my mind when I’m actually in labour!). However, I realise there are a huge number of risks in delivering a baby at home, which is why I’d never choose a homebirth over a hospital birth. When I go into labour, I will try to go as “natural” as possible in a hospital setting, but remain open to the notion that medical intervention may be necessary at some point. In general, I think homebirths are a bad idea. I think sometimes people forget what having a baby was like in the days before modern medicine could assist us.

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Based on the numbers, it looks like we need more nurse midwives doing in-hospital births.

8

Very interesting and important data.

I have one question though. Is this including c-sections/ emergency c-sections as well? I was just thinking that if c-sections were NOT counted, then maybe there were more hospital births that would have had low apgars or whatever, but actually ended up as c-sections rather than being naturally delivered (and thus excluded from the hospital data, whereas at a birthing center or home, c-section is much less likely meaning those low apgar scores would be counted in the data).

No value judgement here, I had my kiddo in the hospital with a midwife. [name]Just[/name] musing. :slight_smile:

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Interesting, I think, but I am very bad with numbers so not sure how much I actually understood… :wink:

I hope I can have a home birth with this baby, and my doctor told me as long as it’s not your first baby, giving birth at home is just as safe as doing it in the hospital. Here in [name]England[/name] your midwife will come and be with you during the birth though, and you will be strongly advised against home births if it’s your first baby or there’s anything that could cause complications. But I guess these things are different?

10

My husband’s cousin has 8 kids, and the last 6 were born at home. She has had no problems. But I have another friend who tried to have a home birth with #1 and ended up being rushed to the hospital when it was discovered at the last minute that the cord was prolapsed. [name]Baby[/name] was without oxygen for nearly 10 minutes and suffered permanent brain damage. That is enough to make me glad that I have always chosen a hospital birth. I have many friends who advocate home birth and are constantly citing statistics which show higher maternal mortality rates in the hospital, but I suspect (like you mentioned, blade) that this also includes all of the home birth mothers who had complications and were rushed to the hospital to try to save them.

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[name]Just[/name] had a flashback to stats class - the horror!

Thanks for posting the information [name]Blade[/name]. As someone currently TTC, it is very beneficial.

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Yep I remember reading (when I was convinced I wanted to be a midwife) that the British Medical Journal published a study on how it’s just safe to be at home for baby #2 and subsequent children. And RCM encourages home births for uncomplicated pregnancies. I think we do things a tad different over here though!

With possible future babbas with smooth pregnancies, I think I’d want home births. I know I’d be waaaaaaay more comfortable in my own home than in a hospital. But we’ll see :stuck_out_tongue:

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C&P; I don’t remember exactly how many my doctor said, but I think it was 45 out of 100 first baby home births that were brought to hospital, and 12 out of 100 for second or subsequent babies. Also serious injuries/death is extremely rare, so I think it’s better over here. But we’ve got free health care, so I guess that’s a part of it too.

It sounds so much more relaxing at home! Especially when you already have a child, and we’ll be in our new home by then (if we get the house we want we’ll be really far away from a hospital with a maternity ward). I just hope I’ll find a nice midwife out in faerieland!

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My best friend is due to have a baby any day now and she is having a natural birth in a hospital, because she is well aware of how bad home births can go. She was born at home (as 90% of my friends/acquaintances were) and her mom was very confident about it because her brother was such an easy birth, she pushed for like 15 minutes and he was out with no issues. My friend on the other hand, turned out to be a very complicated birth and her shoulders got stuck. Her mom (and her, probably) almost died. Her midwife was a friend who was a nurse practitioner (she worked at a women’s clinic and mostly performed abortions) knew what to do somehow and got her out in time. I think everyone should have the right to have a home birth if they want one, but just know the facts and be prepared if anything goes wrong.

Here is my opinion/thoughts on home birth via [name]Patton[/name] Oswalt. Some foul language and crudeness, just a warning. [name]Blade[/name], I think you’ll like this. :smiley: Patton Oswalt - Birth - YouTube

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Thanks blade a good reminder to everyone as these stats clearly state that it is MUCH more dangerous to have a home birth than a hospital birth.

I had extremely complicated problems with my pregnancies and I would not have survived without a doctors intervention and neither would my babies.

Please ladies go to a hospital birthing centre where you have the midwives and the doctors on hand to help you.

And if you are considering a home birth think again make sure you have all the facts, and especially do not do it as an economy measure.

rollo

16

Thanks for posting this, stats are more than just the headlines and people forget that often hospital stats include the worst case scenarios that need to be rushed to hospital and indeed the cases where the birth was high risk (outside multiples and prems as you pointed out [name]Blade[/name]). With this considered if the outcomes for each setting were only equally good/bad…think of what an excellent job those doctors and nurses in the hospitals are doing with all those tricky cases! Pregnancy and childbirth were and continue to be killers of women (check out international stats ladies), just because they’re natural doesn’t make them nice or safe.

I was a (first time!) home birth and just feel so lucky that nothing went wrong! I can’t believe for a second that my mum had all the facts >.> I love her dearly but that was not her best choice (She was 30 and obese! Who let that happen???!).

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What’s odd is there are usually CNMs in more populated areas who attend home births, at least enough to cover the demand. I don’t know if it’s cost, availability, lack of information/ research, or something else that causes women who opt for home birth to choose a different type of midwife, but I’d be interested to know the motivation behind that.

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Oh how I wish this was an option for me. The only birthing center in my metro area is NOT attached to a hospital. Pretty much, if I want to birth with a CNM, I can do it at the birthing center or in my home. I could be wrong, but I don’t think that there are many areas in the US that have true midwife run birth centers attached to hospitals. If I choose a hospital birth, I will have intervention after intervention pressed upon me, making my birth much more stressful than it would be if I could trust the attendants to just leave me alone unless something was wrong. Then I’ll have people bugging me from sunup to sundown following the birth, keeping baby and me from sleeping, nursing, etc. I’m sure there are US hospitals where this is not the case, but most of us don’t have access to them :frowning:

That said, this paper convinced me not to go with the local birth center, so thank you, [name]Blade[/name]. I’d rather deal with the aforementioned complications than mourn a dead or neurologically impaired baby. We’ll just be bringing a doula and checking out as soon as I am physically able :slight_smile:

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You were obviously a terrible candidate for home birth then, that doesn’t mean everyone is.

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Seems very country specific info - in [name]New[/name] Zealand, it is the same midwives (all competent, trained professionals) who attend both hospital and homebirths. No wonder birthing at home is such a safe option for so many women here :smiley: