In the first part of this discussion, we began reviewing Dr. Erin Tracy’s article posted online at OBG Management, entitled “Does home birth empower women, or imperil them and their babies?”
To Dr. Tracy’s credit, she does state that the hospital environment needs to be made more nurturing and supportive of women’s choices, and that perhaps we need to find new terminology to replace words that imply failure on the laboring woman’s part (failure to progress, incompetent cervix, inadequate pelvis, etc.). However, I disagree with some of Dr. Tracy’s conclusions.
Dr. Tracy states that homebirth studies are difficult to extrapolate accurate data from, for several reasons:
lack of follow-up after the delivery
varying definitions of perinatal mortality internationally
lack of clarity regarding the identity and education of delivering providers
the fact that there are often “too few neonatal deaths from which to extrapolate reliable rate calculations.”
I would argue that each of these factors can also be present in hospital births. Do we have long-term follow-up on women who are discharged from the hospital 24 hours after delivery? Most midwives who attend home-births are in contact with their clients much more frequently and for a more extended period of time than obstetric providers within the hospital. For example, in my homebirth/birth center practice, I typically did a home visit at one day postpartum, three days postpartum, and an office visit at one week, two weeks, and six weeks postpartum. This was the minimum. If a woman was having difficulty with breastfeeding or depression, I would be seeing her more frequently. Contrast that with my current practice, where a woman who has a normal vaginal delivery is seen one time postpartum, at her 4-6 week checkup.
In a hospital, you may have multiple providers of varying educational levels caring for you. Medical students, residents, attending physicians, nurses, nursing students, and so on, may all be involved in your care. While it is true that direct-entry midwifery is not uniformly standardized as to educational requirements, experience, etc., this is changing. Standards are becoming more consistent from state to state, and I believe will continue to become more consistent as more states license and regulate certified professional midwives (CPMs). I believe that even now, in states that license CPMs, standards are fairly consistent.
Differences in definition of perinatal mortality are primarily a problem in the United States. As we saw yesterday, other countries have much more rigourous and well-defined criteria for identifying perinatal mortality. However, based on the wide-spread media coverage of any adverse outcome from a home birth, I believe that there is no problem identifying perinatal mortality when it occurs out of the hospital. On the contrary, there are more likely to be adverse outcomes that have been unnecessarily attributed to birth occuring outside the hospital, because of the lack of objectivity in much of the media.
Finally, Dr. Tracy states that in the studies she reviewed, there were not enough newborn deaths to extrapolate accurate information. Let’s think about this for a moment. Not enough newborn deaths? Isn’t that a good thing?
Dr. Tracy goes on to describe the 2005 BMJ study which concluded that home birth is a safe option for low-risk women with an experienced birth attendant. She states that one of the flaws of this study is that data for the comparison group was obtained from birth certificates, which do not include important risk factor information. Dr. Tracy fails to mention that the authors of the BMJ study address this concern:
“One exception, and an important adjunct to our study, was Schlenzka’s study in California. In this PhD thesis, Schlenzka was able to establish a large defined retrospective cohort of planned home and hospital births with similar low risk profiles, because birth and death certificates in California include intended place of birth and these had been linked to hospital discharge abstracts for 1989-90 for a caesarean section study. When the author compared 3385 planned home births with 806 402 low risk hospital births, he consistently found a non-significantly lower perinatal mortality in the home birth group. The results were consistent regardless of liberal or more restrictive criteria to define low risk, and whether or not the analysis involved simple standardisation of rates or extensive adjustment for all potential risk variables collected.“
Dr. Tracy furthermore views this study as flawed, because, as she states,
“. . . although the authors of this study asserted that they had no conflict of interest, the investigation was funded by The Foundation for the Advancement of Midwifery.”
Receiving funding from this organization does not necessarily indicate conflict of interest. Conflict of interest only exists when data is interpreted inaccurately, to reflect what the authors wish it to reflect. The authors of the study state:
“Funding: The Benjamin Spencer Fund provided core funding for this project. The Foundation for the Advancement of Midwifery provided additional funding. Their roles were purely to offset the costs of doing the research. This work was not done under the auspices of the Public Health Agency of Canada or the International Federation of Gynecology and Obstetrics and the views expressed do not necessarily represent those of these agencies. “
It is interesting that Dr. Tracy does not mention that the primary source of funding was the Benjamin Spencer Fund.
Dr. Tracy then proceeds to point out that several studies concluding that hospital birth is safest are also flawed, yet goes on to use their data to support her assertion that perinatal risks are higher when birth occurs outside of the hospital.
In tomorrow’s post, we’ll conclude this discussion by examining some of the factors Dr. Tracy believes make out of hospital birth inherently more dangerous.