Does her research:

“You also evade the question of why the Netherlands can have such success with home birth and care, while their resources as a nation are so close to ours–the fact is that we can learn from the Netherlands,”

I’m not evading the question; I’m pointing out that the mortality rate in the Netherlands tells us no more about the safety of midwifery than the mortality rate in sub-Saharan Africa tells us about the safety of midwifery. The fact that midwifery advocates point to the Netherlands only tells us that they don’t understand statistics.

The neonatal mortality rate in a given country is a function of obstetric care and neonatology care, not midwifery care. Why? Because midwives care for low risk cases in which very few complications will occur. Neonatal mortality predominantly occurs among premature babies, babies with medical problems, babies born to mothers with pre-existing medical conditions and babies born to mothers with pregnancy complications. Midwives REFER these patients away to obstetricians. The only way to determine the safety of midwifery care is to compare midwifery patients with physician patients of comparable risk. That means patients who are low risk, at term without pre-existing medical conditions or pregnancy complications.

Midwifery care is safe when nothing goes wrong. There’s no question about that. The issue is what happens when something does go wrong. The survival of the mother and baby then depend on how far away they are from emergency personnel and equipment. The incontrovertible fact is that midwives, even the best midwives, cannot deliver a baby by C-section, cannot operate to prevent maternal hemorrhage and are not experienced in expert neonatal resucitation. If a mother or baby needs those things, a doctor is the only person who can help.

Birth centers and midwifery care are safe ONLY if midwives refer away patients who are likely to develop significant problems. Even then, some unanticipated problems will occur. The odds of that happening are low, but not zero.

Does her research:

“The peer reviewers at BMJ found it to be valid”

The peer reviewers at the New England Journal of Medicine found the Vioxx studies to be valid, but they weren’t were they?

“N Engl J Med. 1989 Dec 28;321(26):1804-11″

That’s not a scientific study and it’s not about homebirth. The other studies are not about homebirth, either.

If you want to talk about midwife led units, we can do that, too. NICE (National Institute for Health and Clinical Excellence) in the UK recently completed a comprehensive evaluation of all existing studies on birth centers and homebirth. Their conclusions are:

“Birth outside a [physician] led unit is consistently associated with an increase in normal vaginal births, an increase in women with an intact perineum and an increase in maternal satisfaction. The quality of evidence available is not as good as it ought to be for such an important health care issue, and most studies have inherent bias. The evidence for standalone midwife led units and home births is of a particularly poor quality.

The only other feature of the studies comparing planned births outside [physician] units is a small difference in perinatal mortality that is very difficult to accurately quantify, but is potentially a clinically important trend. Our best broad estimate of the risk is an excess of between 1 death in a 1000 and 1 death in 5000 births. We would not have expected to see this, given that in some of the studies the planned hospital groups were a higher risk population.”

“thanks to Papaya for bringing up Holland”

Another example of erroneous reasoning. The low neonatal mortality rate in the Netherlands tells us NOTHING about the safety of midwifery care. Afterall, all the countries with the WORST neonatal and maternal mortality rates have very high rates of midwifery care. Should we conclude from that that midwifery care is unsafe?

“Isn’t it more valuable to present the outcomes and recommend to women who want to avoid unecessary intervention that in the majority of cases, midwife-led care is safe as long as there is access to OB-led hospital care when things turn pear-shaped?”

Yes. However, it is important to present all the information, not just the information that makes midwifery care look good.

Does her research:

“Read the study in its entirety …”

That’s right. Read the study and analyze it and you will find that the Johnson and Daviss study ACTUALLY shows homebirth to have a neonatal death rate several times HIGHER than hospital birth.

First, a little background is in order. Johnson and Daviss are not independent researchers. Their study was comissioned by the North American Registry of Midwives. In the paper, Johnson describes his professional position as “senior epidemiologist, Surveillance and Risk Assessment Division, Centre for Chronic Disease Prevention and Control, Public Health Agency of Canada”, but he neglected to mention that he holds another position: head of the Midwives Alliance of North America Statistics and Research Committee. In fact, Johnson and Daviss have been passionate homebirth advocates for many years, long before they embarked on the study. Daviss, who is Johnson’s wife, is a homebirth midwife. Furthermore, the study was not funded by an academic institution or a government agency. Rather, it was funded by Foundation for the Advancement of Midwifery, a homebirth advocacy group.

So using money from a homebirth advocacy group, NARM, a homebirth advocacy group, hired homebirth advocates Johnson and Daviss to produce a study on homebirth. The conclusion appears to be predetermined. When an industry hires known allies to do a study about that industry, the results are going to be favorable.

Now let’s look at the study.

The Johnson and Daviss study ACTUALLY shows homebirth to have a substantially higher neonatal death rate than hospital birth. They just left that information out of the study. Look through the study very carefully. Can you find the neonatal death rate for low risk white women in the hospital in 2000? No, you can’t because it was omitted from the study. According to CDC data, the death rate in the hospital was approximately 0.72/1000, substantially less than in the homebirth study.

The Johnson and Daviss study, like other studies that CLAIM to show that homebirth is as safe as hospital birth compares homebirth to overall neonatal mortality (including all races, premature babies, multiple births, breech, pregnancy complications and pre-existing medical conditions). A fundamental principle of scientific research is that you must compare like to like. In order to know if homebirth is safe, you MUST compare it to low risk white women at term without pre-existing medical conditions or pregnancy complications. None of the studies that claim to show homebirth is safe actually do that.

The Johnson and Daviss study, a study commissioned by a homebirth advocacy organization, funded by a homebirth advocacy organization and conducted by homebirth advocates, is scientifically invalid. It does not compare homebirth with hospital birth for low risk white women at term. That’s because the hospital neonatal death rate for low risk white women at term in 2000 was much lower than the homebirth death rate, so they just left the hospital death rate out.

Doing your research means more than just knowing that a scientific paper exists. It means reading and analyzing the paper to determine if the conclusions are valid.

Anti-homebirthers frequently ignore the dangers inherent in a hospital. For example, there is no staph in my home. I know several people who have contracted staph and strep in the hospital, when they had neither before they went in for unrelated issues.

Thanks to Chiara for putting it so well. Sarah, Goon Squad Sarah is chasing poor science with an anecdote, and in doing so, menacing women who choose the midwifery model over the medical model, which could actually be characterized as more risky, according to BMJ–British Medical Journal. In a study that tracked 5400 home births here are the stats: “655 (12.1%) women who intended to deliver at home when labour began were transferred to hospital. Medical intervention rates included epidural (4.7%), episiotomy (2.1%), forceps (1.0%), vacuum extraction (0.6%), and caesarean section (3.7%); these rates were substantially lower than for low risk US women having hospital births.” (Read the study in its entirety on http://www.bmj.com/cgi/content/full/330/7505/1416). That’s a rate of less than 4% caesarean versus the national average of 29% for hospital births. Caesarean sections are much riskier than vaginal births for many reasons–a woman will lose on average 3 times the amount of blood that she does in a normal vaginal birth, has a much greater risk of infection, and for what? Does this not indicate that 80+% of caesareans were probably unecessary and the result of a cascade of interventions that the medical model deems necessary for a “delivery” to take place. It is the combination of defensive medicine–IE doctors beholden to insurers who encourage them to intervene in order to prevent risk and the hysteria in our culture that characterizes birth as dangerous and a process of doctors rescuing babies from mothers’ delinquent bodies that make these numbers possible.
I urge the reader who has a low risk pregnancy to take Sarah, Goon Squad Sarah’s entry at face value–it’s an extraordinary birth story that included a lot of medical intervention for good reason. However, if your pregnancy is low risk and you are interested in a midwife-attended birth, don’t be discouraged. The numbers are on your side that you will avoid surgeries like c-sections and epesiotomies if your primary attendent is trained to treat birth as a normal function of the female body, rather than one who is primarily trained in pathology. You want those people around when you sever a limb, have cancer or a an auto-immune disease, not when you are having a baby.

My very brilliant wife said something to me the other day about home birthing after watching Ricky Lake talk about childbirth…

“Home birth proponents are putting the focus on the wrong person… Shouldn’t the focus on childbirth be on the baby and it’s well being not the mothers comfort and empowerment?”

I agree with this article. At the same time I wish I was confident enough to have a home birth drug free and barely a midwife to assist. How awesome would that be? I considered it, I thought to myself, women have been birthing babies with and without midwives for thousands of years. But as my doctor so aptly put it ” One in four women also died during natural child birth.”

Why would I take that chance with myself and my baby?

I think it is absolutely a woman’s perogative either way and neither decision should be admonished.

Wow, what a completely irresponsible, biased article. No midwife in a freestanding birth center would TAKE a woman having a complicated pregnancy like yours.