Born in the USA (26 page)

Fear-mongering and nonscientific public statements against ABCs have not been limited to Illinois. In 2001, the Texas State Board of Midwifery was considering rule changes for midwives working in ABCs. A neonatologist in Austin sent an unsolicited e-mail message to the board of midwifery expressing his opinion that out-of-hospital birth with midwives is dangerous. To prove his point, he described a recent birth in an Austin birth center in which the newborn baby had difficulty breathing—difficulty that was almost certainly due to a genetic blood disorder, the presence of which the birth center had nothing to do with. His description of the case (with which he had absolutely nothing to do) was wildly inaccurate, beginning with his statement that the baby had died, when, in fact, the baby is very much alive. He also said the baby was Hispanic, which it is not, and that the pregnancy was high-risk, which it was not. He also said that putting a woman in labor in a warm bath is dangerous, which it is not.

In fact, when the board investigated, they found that it was a midwife from the ABC who noticed the baby's breathing difficulty (which was not present when the baby left the ABC) during a visit to the family's home the day after the birth and urged the family to seek medical attention. Ironically, rather than illustrating that ABCs are dangerous, the case illustrates the value of midwifery and the value of the close follow-up provided by the ABC. So the doctor's e-mail message had an effect opposite to what he intended—it drew to the board's attention the value of the ABC's care.

The neonatologist's e-mail message to the board of midwifery is an example of the way local doctors talk to one another behind closed doors whenever an out-of-hospital birth is transferred to the hospital, condemning the midwife and the family before they know the facts. The director of the ABC wrote to the board that the neonatologist “knowingly distorted this situation in order to block the new midwifery rules” and that he “considered the ABC an easy target which could be attacked to accomplish the blockage of any rules which he perceives give midwives greater power.”
¹⁶

This ABC has every right to be offended by someone spreading false information about its practice. Using families, health professionals, and health facilities for political gain and to promote selfish territorial concerns is inexcusable. In addition, such tactics invade the family's privacy by broadly disseminating inaccurate information in a message in which their child is easily identifiable.

In
chapter 2
, I described how obstetricians in Iowa managed to close down an ABC that they feared would take their patients away by seeing that no physician in the area would provide backup. These are just a few examples. Yet, in the face of all this obstetric aggression, American women continue to support birth centers. There are now 160 freestanding ABCs in the United States, and there is a National Association of Childbearing Centers that is working to promote ABCs as a real choice for birthing women.
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There is even talk of a new ABC opening in the same city in Iowa.

If anything, the propaganda campaign against planned home birth is even more aggressive than the one against birth centers, and for the most part, the media have been happy to assist with coverage that is sensationalist, to say the least. There's something about the drama of a woman giving birth in her own home that the media just love. An article in the
New York Times
quoted a top public health official in Connecticut: “While home births are legal in Connecticut, women do not have an absolute right to one, in the absence of a licensed nurse-midwife or doctor, ‘any more than they have a right to have brain surgery at home,' said Stanley K. Peck, the Department of Public Health's director of medical quality assurance.”
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Vivid but misleading quotations such as this make good copy.

Once it was firmly established in the scientific community in the 1970s that any study of home birth must make the distinction between planned and unplanned births, study results have continued to show that home birth is a safe alternative for women. In the 1980s and 1990s, a number of small studies were conducted in Kentucky, Missouri, South Carolina, Tennessee, and California that prove that midwives are fully competent to assist at
home births, and an excellent review and meta-analysis of these studies, published in 1997, concluded that planned home birth, when attended by either a nurse-midwife or a direct-entry midwife, is safe.
¹⁹

Then in late 2001 and early 2002, two new studies of home birth were presented within a few months of each other. One was presented at the annual meeting of ACOG and the other was presented at the annual meeting of the American Public Health Association. It is no accident that these two studies, which were presented to two very different groups of health professionals, had opposite methodologies and came to opposite conclusions. So it behooves us to take a closer look.

The first study, presented to ACOG by J. Pang and colleagues, is titled “Outcomes of Planned Home Births in Washington State: 1989–1996.”
²⁰
Though the title uses the phrase
planned home birth
, the methodology used makes it impossible to tell if any of the home births were actually planned or intended. The study relies solely on birth certificate data that indicates actual place of birth but does not indicate the planned or intended place of birth. The only way these data could be valid is if researchers were able to follow up on individual cases to determine the intended place of birth, but in this study they could not do that because their research was approved only for “birth certificate data from unidentified participants.”

In the study, the researchers attempted to “minimize misclassification of intended location of delivery,” but they freely admit “the potential for misclassifying unplanned home births as planned home births.” Finally, they say, “Since we tried to minimize misclassification, but had no possibility to eliminate it, there remains potential for a significant amount of misclassification of accidental or unplanned home births as planned home births.” In other words, the authors of this study did not heed the legacy of scientists that came before them and repeated earlier mistakes by failing to make the essential distinction between planned home birth and unplanned home birth.

It's interesting to look at the kinds of cases that were counted as “planned” home births. In one example, there was a precipitous (unplanned) home birth of a full-term baby. Then the family went to a hospital to have the woman and baby checked. While at the hospital, a midwife, nurse, or physician certified on the birth certificate that the birth had occurred at home. For the study, the birth was counted as a
planned
home birth, because it satisfied the study's definition of a planned home birth: “those singleton newborns of at least 34 weeks gestation who were delivered at home and who had a midwife, nurse, or physician listed as either the birth
attendant
or certifier
on the birth certificate.” In Washington State, attending home birth is not within the scope of practice of registered nurses, and the Midwives Association of Washington State knows of no physicians in the state who attend planned home births.
²¹
Therefore, home births certified by a nurse or doctor are most likely not planned home births. By including these cases in the planned home birth group, the researchers increased rather than minimized the misclassification of unplanned home births as planned home births.

Hospital transfers were another source of misclassification in this study. The researchers identified hospital births that started as home births and were transferred to the hospital and placed them in the home birth group. This would be correct methodology, except that the researchers had no way of knowing if the birth started at home because that was the plan or because the family was delayed in getting to the hospital.

Finally, yet another source of error is simply the high rate of inaccurate data on birth certificates, especially with out-of-hospital births. The authors of the study acknowledged, “A study done by Meyers et al. showed that birth certificate data correctly identified attendant type for out-of-hospital births 30 percent of the time.”
²²

The authors of the study go on to admit that “misclassification of any unplanned home births as planned home births in this study would result in inflated risk estimates of neonatal mortality.” This is because, as the authors also point out, “in previous studies, neonatal mortality among unplanned home births was high (73 of 1,000 to 120 of 1,000 live births).”
²³
Thus, because the neonatal mortality rate of unplanned home birth has been shown to be fifty times higher than with planned home birth, only a small number of misclassified cases would bring more cases of neonatal mortality into the home birth group. In fact, misclassifying only eight cases of neonatal mortality as planned home births that were really unplanned home births would lead to identical neonatal mortality rates in the home and hospital groups. With half as many misclassified cases, any significant statistical difference in neonatal mortality between home and hospital groups would disappear.

This is probably what happened in this study—cases of unplanned home births were counted as planned home births, resulting in inflated neonatal mortality rates in the home birth group. The most important conclusion is that it is impossible to know if this is what happened or if the authors are correct in concluding that there was higher neonatal mortality in the home birth group. The data in this study do not prove either case,
and this study cannot be used as evidence of the safety or lack of safety of planned home birth.

The paper goes on to say that 40 percent of the neonatal deaths in the home birth group were due to congenital malformation, but the authors do not mention that previous research shows a higher rate of major malformations in newborns born to women receiving prenatal care from midwives in Washington State.
²⁴
This higher rate of malformations is probably due to the fact that the women going to midwives for care are less likely to terminate pregnancy. This could also have an effect on the rate of newborn babies dying in the home birth group.

The paper also reports more postpartum bleeding and more prolonged labor in the home birth group, but these “problems” are defined and managed differently by midwives and doctors, so this difference is most likely a difference in the definition of these problems, not in their rate. Furthermore, neither “problem” is an issue unless it is so severe as to lead to other consequences for which the researchers have no data, so it is inappropriate to conclude, as the authors did, that “This study suggests that planned home birth had greater maternal risks.”
²⁵

In the process of “trying to minimize misclassification,” the researchers eliminated several subcategories of low-risk births. To qualify for the study, a birth must be near term, not low-birth-weight, only singleton, and have no pregnancy complications. This narrows the definition of low-risk birth to the point where births in the study's home birth group and in the hospital birth group may be compared, but the groups cannot be compared with other studies. The neonatal mortality rate in the hospital group is very low, lower than reported in other studies of low-risk hospital birth, and is so devoid of risk and removed from reality as to be of little or no use in research on low-risk birth.

Rather than attempting a balanced reporting of facts about home birth, the paper by Pang and colleagues contains a clear bias favoring hospital birth. It is essential that those doing research have no bias that can influence study results. In this study, there were no home birth providers among the researchers, who are like geographers trying to map a country that they have never seen because they believe it too dangerous to go there.

One kind of bias begins with the incorrect use of the phrase
planned home birth
in the title. Throughout the text,
planned home birth
and
intended home birth
are used in situations where intention is not known but is based on assumption, approximation, or an educated guess. Assumptions are clearly weighted toward results that put hospital birth in a positive light.
Other language choices reveal bias in other ways. For example, the statement, “The risk of neonatal death was almost twice as high for infants born to women intending to deliver at home,” sounds rather dramatic until one realizes that the increased risk amounted to only one more death in every one thousand births.

The choice of outcomes to study or not to study also reflects a bias in favor of hospital birth. For example, the same birth certificate data would have allowed comparisons between the home birth group and the hospital birth group regarding interventions such as induction of labor, forceps, vacuum extraction, and C-section. But these interventions were not analyzed. Had they been, it is likely there would have been findings favorable to home birth, since previous research shows significantly lower rates of interventions in planned out-of-hospital birth. The paper does, however, mention advantages of hospital birth, such as the early identification of congenital heart disease.

The literature review in this paper also is slanted to favor hospital birth. It mentions several studies that are small and use questionable methodology and are interpreted to show better outcomes with hospital birth than with home birth. But it does not mention the scientifically valid meta-analysis of home birth studies by Olsen, which showed no increased risks with planned home births.
²⁶
The meta-analysis is in the reference list in the paper, but is conspicuously absent from the review of literature.

The final sentence in the paper is: “Future observational studies using a study design that accurately assesses the intention to deliver at home are needed.”
²⁷
This conclusion is ironic, as it is both an admission that their study did not accurately assess the intention to deliver at home and a plea that such research be done so we can learn the facts about the safety of planned home birth.