Wednesday, 26 November 2008

• The Home Birth Debate

  Even though I have had all my 4 children at home, it was not until I was pregnant with Thomas that I joined natural birthing communities online, and especially the unassisted birthing communities. I wanted an unassisted birth with Thomas and there was a lot to learn and a lot of what if's to answer. Even so, if I had decided to not give birth unassisted in the end, at home is where I planned on giving birth either way. It never once occurred to me nor was there any reason to believe that home birth was anything dangerous and that it would be better to be in a hospital. Where I come from, 30% of women give birth at home (as opposed to 1% in the US), it is considered normal and safe, and it was something I always imagined myself doing. 
  
  Over a 6 month period of time, I learned about all the common possible complications that could occur during a low risk birth, I read and absorbed studies, books, articles, and personal stories. I tuned into the what if's and the spiritual aspect of this birth. My husband and I went to see my midwife and discussed issues that came up for both of us. She is a ND and a midwife, had assisted my previous 3 births and I have always felt her to be loving, very supportive and very knowledgeable ~she is the best really. She also offered to being on call which was very reassuring to my husband. 2 1/2 years later, I still feel confident about this choice. I was simply and deeply called to having this one by myself.
  
  However, the last few months, this one particular blog about home birth, where people are supposed to be able to debate the issue but where the agenda is pretty clear , really drew me in. Especially the claims of the author of that blog, Dr. Amy Tuteur, haunted me. I thought I was relatively educated and here this person claims that everything I believe about home birth is wrong, that people like me are blinded by our bias and deluded by uneducated natural childbirth advocates. Her main points of contention are:
  -home birth has 2-3 times the neonatal death rate of hospital birth and is thus not safe, and
  -midwifery education in the US is inadequate and not comparable to that of Europe, European midwives being college educated.
  
  If this is true, if Dr. Amy is correct, I have to know because I cannot be the home birth supporter and natural childbirth advocate that I am if she is. I can't be responsible for being even the slightest influence on someone choosing a home birth if something goes wrong and everything is out there for us to see it wasn't safe to begin with, nor could I knowingly endanger any child of mine if I were to be pregnant again.
  
  So I went looking, and found that things are not as black and white as they seem when it comes to statistics, and that it all comes down to interpretation and representation. Dr. Amy is basing her first argument on this study*, saying that it actually shows that home birth has 2-3 times the death rate of hospital birth and not that home birth is as safe as hospital birth as the study concludes. She then uses this site to find the numbers of a comparative group to prove her point. Herewith, however, enters the first issue. The Johnson and Daviss study was a prospective study, the numbers of the CDCWonder site are retrospective. This is an important difference because the first follows a group of women with a planned birth place, the second looks at the bare outcome, without including intention. You can find more information about the differences, limitations and other aspects of both types of studies here. The first problem with Dr. Amy's conclusion about home birth safety, or lack thereof, arises because it is often not possible to reconcile the results of one type of study with the results of another type of study. See this post for a more elaborate explanation of this.
  
  Another problem that ties into the above, is that the numbers of the CDC Wonder site need to be interpreted correctly. Reading this post and this post showed me how the numbers on the CDCWonder site do not tell the story behind those numbers. The story is important however, when the numbers are compared to a set of numbers from a transparent prospective study and included in any rating. The numbers of the CDCWonder stats are too narrow to compare with and draw any real conclusions from, as Kathy shows in her posts. 
  
  Also in this article, one can read that there is a deliberate under reporting going on in hospitals:
  

  Furthermore, the cover-up of abortion-related deaths has actually been furthered by the World Health Organization’s coding rule number 12 of the International Classification of Diseases. This rule requires that deaths due to medical and surgical treatment must be reported under the complication of the procedure (embolism, for example) and not under the condition for treatment (elective abortion). According to researcher Isabelle Bégin:

  In effect, this makes the “abortion” category a “ghost” category under which it is simply impossible to code a death due to abortion.

  In other words, anyone can manipulate the numbers to mean what they want them to mean, and not all the numbers are representative for any particular group. In addition, I have found Dr. Amy's comments to the posts linked above to be seriously lacking. Because of this, and because of Dr. Amy's reputation of ending any debate with bullying or condescension, I am tempted to believe that the skewing of data is deliberate on her part. For the longest time, I really wanted to give her the benefit of the doubt because I really wasn't sure and had to be honest to myself about this.
  
  The biggest issue in this debate however, is possibly the issue that the Johnson and Daviss study included intrapartum deaths as well as neonatal deaths in their death rates, but that Dr. Tuteur does not separate the two in her comparison. There are numerous exchanges about this fact on Henci Goer's forum, and a few people have explained this issue from various angles. An interesting and more in depth debate about these numbers can be found in the comments here. Intrapartum deaths are deaths that occur during delivery. Intrapartum deaths are not neonatal deaths and would have been classified as stillbirths in a hospital.  You can't compare Johnson & Daviss' perinatal death rates (stillbirth + neonatal death=perinatal death rate) to the CDCWonder's neonatal death rates, you have to take the stillbirths, or intrapartum death rates out first. This then brings us to a 1.1/1000 neonatal home birth death rate compared to a neonatal hospital death rate of 0.9/1000. And this is before taking out the death that occurred to the baby of a non-white mother (since the hospital neonatal death rate is calculated for white women), a group that statistically has a higher neonatal death rate. And then of course we should exclude home twin and breech birth from the home birth numbers, because those would be considered high risk in the hospital setting. The CDCWonder does not allow us to exclude breech birth from the numbers, but we know that those would be mostly c-sections in a hospital setting and thus not attended by CNM's. Do you get what this means...? The difference, if we could really compare like with like to begin with, becomes statistically insignificant in my opinion. Moreover, Dr. Amy has yet to explicitly show, with numbers and where to find them, how she gets a low risk home birth neonatal death rate of 2.7/1000.  The comments here clearly show how she refuses to answer the question and how she again, takes her recourse to bullying.
   
  What really struck me however, when perusing the Woman to Woman Childbirth Education blog is this entry about the number of pre-term abortions of babies with so called unavoidable lethal anomalies. That number is 95% according to this site. Approximately 95% of anencephalic babies are aborted before birth, according to the Kennedy Institute of Ethics at Georgetown University. This rate is similar for other birth defects.  In northern California, for example, 95% of unborn children diagnosed with cystic fibrosis are aborted, according to the insurer Kaiser Permanente. As Kathy says, the neonatal statistics don’t take into account abortions for known or suspected fetal anomaly; and I think it’s pretty obvious that home-birthing women are less likely to have an abortion than the hospital population. I agree with that. The number of home birthing mothers is very small, and those women most likely have a different attitude, philosophy and outlook on life than someone who does not choose home birth. I did not want any scans with any of my pregnancies for example, and I would not abort a baby with a lethal anomaly even if I had a scan that showed this. Most women having obstetric prenatal care will at least have 2 ultrasounds if I am correct (though of course a woman can refuse those if she doesn't want them). This is generalizing but it is more than plausible that the number of babies with a lethal defect born to a home birthing mom are going to be higher, and statistics could indicate this as Kathy suggests.  It can also be that a number of moms would actually choose a home birth when they know their baby will not live. Also, babies born with lethal anomalies can be kept alive longer in a hospital setting, whereas home birth parents may choose to not intervene. To simply say that home birth has a higher rate of preventable mortality, as Dr. Amy says they are, without looking at what qualifies the numbers, is disingenuous at best.
  
  Anyway, I think that I have reached full circle with this issue finally once and for all. Even if some of the points brought up here are not as accurate as they could be, and I am open to correction, there is enough doubt in my mind about the validity of Dr. Tuteur's claims. When someone presents something like statistics as black and white as she does, one has to wonder about their conclusions really. The whole premise of Dr. Amy's blog is that home birth is dangerous and that women choosing home birth are stupid, choosing an experience over the life of their child. It is really rather compelling, especially when so many highly educated and articulate women participate and share their similar views with even more conviction because they have the personal experience to back up their claims.
  
  One last issue that I would like to touch upon, is that many bad things have been said about Dr. Amy in the public ether. Many people claim she is a scam artist, that her credentials are fake, that she is not an MD let alone an obstetrician or that she is a plant of the ACOG (which could still be the case) deliberately distorting the truth. I myself repeated those claims to anyone who would hear, but I didn't actually look into those claims. When I did look into it more however, it became clear that she is indeed who she says she is, as far as credentials go. However, she is not a currently licensed practitioner and we have no idea why that is for sure. In any case, my apologies to Dr. Amy for perpetuating some of the false claims. Interestingly, it is the falsity of some of these claims that raised questions in my mind about the other claims against her. Could Dr. Amy be right after all? I now truly believe she is wrong in the way she looks at the data, and I am baffled at the amount of vehemence coming from her in trying to prove her argument. At best, we can argue about what constitutes statistical significance and quality of life.
  
  Finally, I am aware of the fact that I have put things a little simplistically here perhaps. This is why I included so many links to Kathy's blog. She does a better job than I ever could and enabled me to understand this more deeply. This issue has also been discussed on Henci Goer's forum, which has also been very helpful.
  
  I am doing some more reading about Dr. Amy's second claim and will write more about this later.
  
  *The authors of the Johnson and Daviss study acknowledge and explain the deficiency of the study here.
  
  

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