Wednesday, July 23, 2008

Home Births

For a variety of reasons, this post is about home births.

I ran across this post (courtesy of the folks at MedBlogs Grand Rounds). I was hoping to find something concrete to reinforce my grudging acceptance of home birthing, as there does not seem to be very much that is scientifically unfavorable out there. Well . . .

Louise (the blogger here) cites an article that shows that outcomes for low-risk women who deliver at home are just as good as those for low-risk women who deliver in a medical setting. I tend to agree with some of what Louise says in the post, like the fact that"medical doctors are a vital part of health care. But they are not the only piece of the puzzle, especially when it comes to childbirth." It makes me think of the countless times I have attended a woman who had the "misfortune" (that's sarcasm, folks) of delivering outside of the hospital; better yet, for how many deliveries does the doctor arrive late?

But there are a couple of points that I can't agree with.

"A long, painful birth in an of itself is not a medical problem." For you, Louise, perhaps, but not for every woman. Painful birth does not harm the mother, although the Scientologists might argue about its effects on newborns. You know, you can go to the dentist and have your teeth extracted and filled without anaesthetic, too, but it's not how I would choose to spend my afternoon. Some women are highly motivated to deliver naturally, but to imply somehow that it is superior to a hospital birth is a bit much to swallow. Not even the study which she cites claims as such.

The study does seem to be well constructed, but I find it interesting that the vast majority of the women were white (89.4%), middle class (59.9%), and non-smokers (94.1%); I suspect that this does not reflect a typical mix of patients in the United States (the study was Canadian-based, but supposedly drew patients from North America). It would be prudent to know what the statistics would be for a more realistic mix of patients. I was also surprised that in the paragraph "Outcomes," the authors mention an actual total of 18 intrapartum and neonatal deaths, but excluded 7 of those 18 (38.8%) in their calculations, for reasons that I am not sure are methodologically valid. And even though the authors admit that "Breech and multiple births at home are controversial among home birth practitioners," there were still 80 planned breech deliveries at home, and 13 sets of twins delivered at home. How did these pregnancies get assessed as "low-risk"? I agree that this study is an important one in actually elucidating the risks and outcomes involved in home births, but it is not the definitive answer.

Louise is not a fan of ACOG. "Unfortunately," she states, "ACOG would like to impose artificial time frames on a natural process that was never set up around a clock or a doctor’s schedule." Whoa--there are no time frames imposed on the birth process. There are practice guidelines that are set up (some proposed by ACOG, some by other entities) that serve as suggestions in improving patient care and outcomes. They are based on actual, peer-reviewed research and studies on patients in labor and what happens when certain events occur in certain time frames. ACOG is not a bunch of old guys sitting around making up numbers to torture women with.

Louise continues: "The conflict of interest for ACOG and the AMA is glaring like a neon sign." How is concern about women's health and childbirth a conflict of interest for ACOG? Oh, wait, she explains it to us: "Every woman who chooses to give birth at home with a midwife means one fewer patient for ACOG. That’s pretty much the whole story."

Huh? ACOG isn't in the business of taking care of patients, doctors are. A woman who gives birth at home, or in a car, or at the hospital probably has no idea who ACOG is or what they do. "So ACOG and the AMA have chosen to take the undeniably sleazy route of hiding their primary interest (money) under the thin disguise of being concerned about the safety of mothers and babies." This statement is so ridiculous that I don't know what to say. Maybe she equates ACOG with BigPharma and the whole military-industrial complex run by the Rothschilds. Exactly how does ACOG make money when a woman delivers?

According to Louise, "each woman should be able to labor and birth where she is most comfortable, and have access to competent, licensed caregivers, regardless of where she chooses to give birth. It seems that ACOG and the AMA do not want to offer me that same measure of respect."

This is an admirable sentiment; I trained alongside midwives as a resident in Texas, and I found them to be knowledgable, competent and compassionate caregivers. But each woman should be offered appropriate info about the benefits as well as the actual risks of home birth, and I am not sure that this is being done. The statement that "midwives generally don’t accept unhealthy women or high risk pregnancies" made me cringe. As opposed to the midwives that I associated with during my training, many of the midwives (licensed and unlicensed) that I have encountered in private practice have seemed unwilling or unable to correctly assess high-risk conditions such as a previous C-section or diabetes.

I could go on and on. What's the bottom line? Louise presents one well-done study suggesting that outcomes in low-risk patients are comparable (not superior) for homebirth and hospital birth. Much of her post is spent demonizing two influential medical organizations, without backing up her opinions. And that's pretty much her "whole story." I was hoping for something a little more constructive.

I am not a fan of ACOG (nor a current member). I have become more open to the idea of home birth as a result of my lovely wife, and her experience with the process. She delivered at home 4 years ago, attended by a midwife. Her older daughter was born at Charity Hospital in New Orleans (I tell Nika that a lot of famous people were born there, but I'm not sure she believes me), and although it was not a bad experience, she much prefers the home birth experience, which for her was extremely positive and healthy. I no longer argue the point with her; who am I to argue with that success? Even though I haven't run across any negative studies comparable in scope and construction to this positive one, I still have some misgivings about it, but I think I deserve some credit for being very open to the idea.

I won't even go into the issues of depth of training, or the malpractice issue (hey--you want to jump in the water, maybe you should swim with the malpractice sharks just like us docs have to do). It's a neat idea to be able to categorize patients into high-and low-risk categories, but it can also be dangerously misleading, for a simple "low-risk" patient can turn into a obstetrical catastrophe very quickly.

I'd like to see more studies like this one. I'd also like to see less posturing by both sides; we don't need ACOG talking about the need to "legislate" the issue, and we don't need Louise or Ricki Lake generally bashing the medical establishment. The word of the day is evidence-based medicine, and not anecdotal-based medicine, something that has been practiced for far too long. More evidence, less rhetoric.


April Dawn said...

I'm only going to comment on the difference between having teeth pulled by another person and birthing pains. One is someone inflicting unnatural pain on someone else suddenly and birthing pains come from within your own body slowly (usually) building up over hours or days usually helped with comfort measures except for maybe the very end when the outcome is a baby. The body is suppose to birth a baby and teeth aren't suppose to be pulled. Apples to oranges.

Small Town Doc said...

You make a very good point; it was a statement made in a humorous vein (a medical pun--yuck), and not meant to be serious. I have never experienced the joys of childbirth, but I have attended thousands of births, and I think I understand that for some women, it is not a very comfortable experience.

I appreciate your comment. Thanks.

Amy Tuteur, MD said...

There were quite a few blog posts written opposing the AMA resolutions. What they all have in common is that they fail to accurately represent the statements of the AMA and they fail to accurately represent the scientific evidence on homebirth.

Here's what the AMA actually said:

1. Homebirth is not as safe as birth in a hospital or licensed birth center.

2. Midwives should be licensed to the standards of the American College of Nurse Midwives.

The fact is that homebirth is NOT as safe as hospital birth. All the existing scientific evidence shows that homebirth has an increased risk of neonatal death. Even the Johnson and Daviss BMJ 2005 study that claims to show homebirth is as safe as hospital birth ACTUALLY shows that homebirth has almost TRIPLE the neonatal death rate as hospital birth in the same year. You can't find that in the actual study. That's because Johnson and Daviss (Johnson is the former Director of Research for the Midwives Alliance of North America) left out the neonatal mortality for low risk hospital birth in 2000. Instead, they compared homebirth in 2000 with hospital birth in a bunch of out of date papers extending back to 1969.

The ACNM standards for midwives ARE the appropriate standards. They are consistent with midwifery standards in EVERY other country in the industrialized world.

Homebirth advocates like to imply that homebirth midwives (direct entry midwives) are just like certified nurse midwives or just like European midwives. That's simply not true. Homebirth midwives are a second, inferior class of midwives with far less education and training than ANY midwives in the industrialized world. American homebirth midwives would not be eligible for licensure anywhere else.

Many homebirth advocates don't realize that the Midwives Alliance of North America (MANA), the trade organization for direct entry midwives, has been collecting detailed safety statistics on homebirths since 2001. They have publicly offered those statistics to organizations that can prove they will used them for the "advancement of midwifery". Even then anyone who is allowed to view the statistics must sign a legal non-disclosure agreement preventing them from disclosing any data to anyone else. It does not take a rocket scientist to surmise that MANA is almost certainly hiding the fact that their OWN data shows homebirth with a direct entry midwife to be unsafe.

The AMA opposes homebirth on safety grounds, and it opposes homebirth midwives because they don't meet the world-wide standard for midwives. These are the real issues, and these are the issues that homebirth advocates perenially fail to address.

Louise Norris said...

This is a very good article. I agree with you on a lot of points. When I wrote my post, I was on the defensive, and my anger towards ACOG and the AMA came through in my writing. I realize that not all OB/GYNs are members of ACOG. But the AMA and ACOG are huge organizations, and well-respected in the US. While ACOG (the non-profit, itself) doesn't make money when women deliver babies in hospitals, ACOG members do - the organization is only as strong as its members, and I assume that the organization speaks on behalf of the obstetricians and gynecologists who are members.

If research shows that planned homebirth is no less safe than hospital birth for low risk women (and you agreed that the study I referenced is a relatively good one), what legit reason would ACOG and the AMA have for actually promoting legislation to do away with legal, licensed midwives and homebirth? I do apologize for being so sharp with my words regarding what I see as a turf war between midwives and doctors. But if money isn't an issue - what is?

You made a good point about how the study on planned homebirths doesn't represent a good cross-section of American women. But it wouldn't be ethical to force women into either a home or a hospital birth for the purpose of research, so all we can use is data gathered from women who choose the option of homebirth themselves. The midwife I used has delivered about 400 babies. I've met many of the other mothers (I realize this isn't a scientific survey) and of the ones I've met, there are no smokers, none are overweight, many are vegetarians, etc. In general, I don't think I'd be out of line to say that women who choose homebirth tend to be more concerned with maintaining their health than a random sample from the population at large. So I doubt that there will ever be a study on homebirth where the percentage of smokers is equal to the percentage of smokers in America. As far as other demographics, again - we can only use data on women who choose homebirth themselves. And this group tends to be represented by educated, white, middle class women, more than other demographics. Not defending this, just pointing it out.

I do believe that an unmedicated birth - at home or in hospital - is superior to a medicated one. I'm entitled to that opinion, but I respect the fact that a woman who plans her epidural long before she goes into labor also has a right to her opinion. Most of my friends have had hospital births. I realize that this is how most women feel comfortable, and I'm glad that the option is there for them. What angers me about the position that the AMA and ACOG have taken is that they would like to see all of us forced into a one-size-fits-all system (ie, birth in a hospital or birth center attached to a hospital), without regard for scientific data or maternal choices.

Small Town Doc said...

Thanks for all the comments. I kind of figured that this post would generate some activity.

Dr. Tuteur--I think I pointed out that the BMJ study excluded a number of neonatal deaths, but I didn't realize that the numbers had been so extensively massaged. Your ideas about licensing standards are important. I agree that there should be one standard that governs midwife licensure; at the very least, it would help to guarantee some measure of quality and safety for moms and babies. The fact that there is a vastly different attitude between ACNM and MANA is disturbing, and should be part of any discussion about home births.

Ms. Norris--Thanks for your comments also. I agree that the BMJ study is a step in the right direction, but one study will not adequately define this issue, and obviously there are some major flaws in the report. We need more studies before we can say in any certain way that home birth is a safe way to deliver.

I don't think money is as big as an issue as you make it out to be (is money behind the midwives' advocacy, too?); to be honest, OB doesn't generate the income that perhaps it once did, and the liability issue is astronomically expensive (this is another issue for another day). I appreciate your statements about the demographics of the home birth population.

I don't agree with trying to "legislate" or force women to deliver a certain way (I'm not even sure that this is what ACOG or AMA is trying to do). But I don't think we are being honest to women by claiming that home birth is as safe as other types of delivery without being able to back that statement up with scientific data. We need that data if we want to truly make such a claim. And despite the good intentions of this study, it has major shortcomings. Dr. Tuteur mentions already existing evidence that shows an increased neonatal death rate. It would be nice to know what MANA is sitting on.

Petronia said...

I wonder how many completely natural births happen in a hospital in the US per year?...I mean, no IVs, nothing. If you ask me, there is something quite unnatural about a healthy mom with a healthy fetus going to a hospital to proceed with the natural process of childbirth--just to be poked, prodded and loaded up with stuff they don't actually need at the moment. Why get loaded with saline instead of drinking good old-fashioned water? Just my opinion. I can't comment on all the research since I wouldn't know anything about that.