Born in the USA (27 page)

The question must be asked: How did this paper ever get published? An editorial in the
New York Times
makes the point that coauthors of scientific papers must carry a “big share of responsibility” for the contents of a paper and are “the first line of defense against fraud.”
²⁸
Where were the five coauthors when the paper was given a fraudulent and misleading title that includes the phrase
planned home births?
At least one of the coauthors is said to be connected with the federal Centers for Disease Control and Prevention and should have recognized that this was false science. Before publication, the paper was presented at a large ACOG meeting. One might hope that at least a few scientists had been present who could point out the serious methodological flaws, but that was not the case. And how did the
flawed paper get by the journal reviewers at
Gynecology and Obstetrics
when there is such hype about the importance of peer review before accepting papers for publication? The same
New York Times
editorial, speaking about another paper published in another prestigious journal, says: “The journal that published the fraudulent papers also needs to raise its guard. Their expert reviewers deemed the findings important enough to publish but somehow missed the fraud underlying them.” The senior author of the paper, Dr. Jenny Pang, told me that before being accepted for publication, the paper had to be revised and resubmitted, so it seems that someone was trying to review it carefully, but, again, missed the basic flaws in the study's design. In the end, a whole system of checks and balances failed to uncover the fundamental flaws in the methodology of this paper.

The other study on home birth, presented to the American Public Health Association in 2001 and published in the
British Medical Journal
in 2005, coincidentally does precisely what the Pang study concluded needed to be done.
²⁹
In October 2001, Dr. Kenneth Johnson, an epidemiologist, and Betty-Anne Daviss, a midwife, presented a prospective study of planned home births attended by certified professional midwives (CPMs) in North America. There are many differences between this study and the Pang study, but one crucial difference is simply that it is a prospective study, whereas the Pang study looked back on births retrospectively. The subjects in the Johnson and Daviss study were identified and recruited into the study as pregnant women, before the birth, so it is possible to clearly determine whether a home birth was intended or planned. The woman could also be followed prospectively, so valid data were available on the outcome of each planned home birth. In addition, there was no mixing of planned and unplanned births as there was in the study by Pang and colleagues.

The study population consisted entirely of clients of CPMs in the United States and Canada who planned home births to take place in the year 2000. For the CPMs, participation in this study was mandatory for recertification. Procedures to validate the reliability of the data were built into the study from the start, including having all pregnant women sign a consent form that included contact information so they could be contacted later. All forms were sent to the study office before the planned home birth. At three to nine months postpartum, study center personnel phoned the women to get information on the birth to validate the information earlier sent by the attending midwife. Data forms were received from 534 practicing CPMs, covering 7,214 births.

In 6.6 percent of the cases, risk factors during pregnancy ruled out home
birth. Of the sample population, 12.5 percent discontinued care with the CPM for a variety of reasons including miscarriage, complications, client moved, changed midwife, and chose hospital birth. As a result, at the time of birth, of the original 7,214 women recruited, 5,358 women (83 percent) intended to give birth at home, 651 women (10 percent) intended to give birth at a birth center, and 431 women (7 percent) intended to give birth in a hospital. All data analysis used the “intention to treat” method in which all cases, including their intervention rates and birth outcome rates, are placed in three categories: intended home birth, intended birth center birth, and intended hospital birth. There were 448 women (7 percent) who had previous C-sections.

Of the home birth cases, 11.7 percent were transferred to a hospital, and of those, 3.5 percent were considered urgent. Time of transfer included 2.1 percent at first assessment, 7.3 percent during the first stage of labor, 2.6 percent during the second stage of labor, 0.4 percent during the third stage of labor, and 1.3 percent postpartum.

The intervention rates were as follows: 2.2 percent of the women giving birth at home received episiotomies. Of cases transferred to a hospital, 0.4 percent involved forceps, 0.3 percent involved vacuum extraction, and 3.7 percent ended in C-section.

There were 5,358 intended home births at initiation of labor. In this group, there were three fatal birth defects, six intrapartum deaths (death occurring during labor or delivery), and eight neonatal deaths, resulting in an intrapartum plus neonatal death rate of 2.6 per 1,000 intended home births. There were no maternal deaths.

In summary, this prospective, highly reliable study, which followed the course of more than seven thousand pregnant women planning home births attended by CPMs, collected data on more than five thousand women who intended home birth at initiation of labor. Among these women, the obstetric intervention rates were far below the rates reported in low-risk hospital births. The combined intrapartum/neonatal death rate (babies dying during labor, birth, or shortly following birth) was as low or lower than rates reported for low-risk hospital births. And the maternal mortality rate was zero. This study is by far the largest scientifically valid study of planned home birth ever conducted. We now have good, solid scientific evidence that makes clear that planned home birth attended by a midwife is a perfectly safe option for the 80 to 90 percent of women who have had normal pregnancies.

In addition to the scientific research on home birth, there is other evidence
that home birth is a safe option. Whenever I discuss home birth with obstetricians in the United States, I need only ask, “What about the Netherlands?” to see their faces fall. The Netherlands has a long tradition of planned home birth. As recently as thirty years ago,
half
of all births in the Netherlands were planned home births. The percentage fell to one-third in the 1980s, but the rate has been climbing for the last ten years and is now more than one-third—36 percent. The Dutch do not have significantly more women and babies dying around the time of birth than other Western European countries, and they have lower mortality rates than the United States does.

Obstetricians can be very creative when they try to explain away the Dutch experience. It would be amusing if it weren't so pathetic. I have heard many U.S. doctors say that the Dutch success with home birth is due to the fact that they have a homogeneous population. To this I have two responses. First, it is simply not true. There are many “minority” groups in the Netherlands. For example, the percentage of Netherlands citizens with Southeast Asia backgrounds is comparable to the percentage of African Americans in the United States. Second, think about what these doctors are saying. This statement reveals a subtle racist arrogance that I find offensive. Their implication is that the United States has more dead babies than other countries because there are minority groups in the United States. But if maternal and infant mortality rates are higher among minority women and babies in the United States, why isn't the obstetric establishment working to change that, for example by campaigning for federal and state legislation guaranteeing all pregnant women in the United States prenatal care and care during birth regardless of ability to pay, such as European countries have? It gives the perhaps partly unfair but nevertheless bad impression that obstetricians would rather use minority groups as an excuse for their high failure rates than take responsibility for improving.

I have also heard U.S. obstetricians try to explain away the Dutch success with home birth by saying that Dutch women have bigger pelvises than American women and their babies are smaller. I've asked to see the data to back up these remarkable statements, but as yet they have not materialized.

I have also heard another explanation for the success of home births in the Netherlands—the idea that distances between a woman's home and the hospital are shorter there. But, based on extensive experience, the Dutch have established thirty minutes as a maximum transport time from home to hospital for a safe home birth. So, when I hear this excuse from an American obstetrician, I ask, “How many homes in your state are more than thirty
minutes from a hospital?” Common sense tells us that very few homes in the United States are more than thirty minutes from a hospital.

Finally, obstetricians in the United States seem to have the idea that obstetricians in the Netherlands do not believe in their home birth system. I have visited the Netherlands dozens of times and have lectured at many large Dutch conferences. I have spoken to hundreds of Dutch obstetricians. I know for a fact that the vast majority of Dutch obstetricians believe firmly in their present system. The Dutch track record with planned home birth is an enormous thorn in the side of American obstetricians.

I've asked myself why obstetricians in the United States find it so hard to believe that a country where one out of every three babies is born at home has a lower infant mortality rate than the United States does. In my view, it goes back to their fear of birth and their belief that without obstetric technology and expertise, babies will die. When confronted with the scientific evidence and the Dutch track record, most obstetricians reply, “But what if there is an out-of-hospital birth and something happens?” This “what if” question reveals several false assumptions worth examining.

The first assumption is that during birth things happen fast. In fact, with very few exceptions, things happen slowly during labor and birth and a true emergency when seconds count is extremely rare. Have you ever spent time in a hospital labor and delivery ward? The atmosphere is not like the ER but rather, for the most part, quiet and peaceful. Regardless of what is seen in movies and television, nobody is running around. It's also important to remember that if trouble does develop, a trained midwife who is providing constant one-on-one care to the birthing woman has a better chance of anticipating it or recognizing it quickly than a labor and delivery nurse or a doctor in a hospital who is responsible for several women in labor and can look in only occasionally.

The second false assumption is that when trouble does develop, there is nothing an out-of-hospital midwife can do. This assumption can be made only by someone who has never observed midwives at out-of-hospital births. Again, with few exceptions, an out-of-hospital midwife can do everything that can be done in the hospital, including giving the women oxygen. The condition known as shoulder dystocia (when the baby's head comes out but the shoulders get stuck) is another example. The only way to solve the problem is to maneuver the woman and baby, and that can be done just as well by a midwife in an ABC or home as it can in a hospital. The most successful maneuver for shoulder dystocia that's been reported in
the obstetric literature, by the way, is the Gaskin maneuver, named after the home birth midwife who first described it, Ina May Gaskin.
³⁰

The third false assumption revealed in the “what if” question is that if there's a problem, there will be faster action in a hospital. That might be true if the doctor happened to be in the room, but the doctor is not even in the hospital most of the time. If there's a problem, a nurse has to call the doctor, and the doctor's “transport time” to the hospital is usually as long as the woman's “transport time” to the hospital if she is in a birth center or at home.

Within a hospital, even when an emergency C-section is indicated, it takes thirty minutes, on average, for the hospital to set up for the surgery, locate the anesthesiologist, and the like. In one study that looked at 117 hospital births where there were emergency C-sections for fetal distress, in 52 percent of the cases the time between the obstetrician's decision to do a C-section and the time the actual incision was made into the woman's belly was more than thirty minutes.
³¹
So, when there is the need, during this thirty minutes, the out-of-hospital obstetrician or the out-of-hospital birthing woman—or both—can be in transit to the hospital. Again, this is why it is important that an out-of-hospital midwife have a good collaborative relationship with the hospital, so when she calls to inform the hospital that she is transporting a birthing woman, hospital staff will waste no time in making arrangements.

Unfortunately, hospitals are often not open to developing this kind of relationship. Because of the irrational fear and anger many doctors and nurses have around home birth, too often there is little or no communication between home birth midwives and hospital staff. When a midwife calls and says that she is coming in, if hospital staff are resistant to home birth, they may fail to prepare for the woman and baby in a timely way. If the hospital staff don't see the midwife as a trained professional who can contribute greatly because she has been the woman's primary maternity care provider, when the midwife arrives at the hospital with the woman and the baby, all information about the pregnancy and what happened during the birth is lost. Since hospital staff are often abusive to both the midwife and the parents who have chosen a home birth, midwives may hesitate to call for advice or to transport a woman to the hospital when signs of trouble first appear. Thus, unnecessary delays in treatment are one of the tragic effects of the marginalization of midwives and false assumptions about home birth in the United States

An irrational fear of out-of-hospital birth can also blind obstetricians and neonatologists to what is really going on in a particular case. I've seen it happen
many times. In one case, in Florida, a woman planned an out-of-hospital birth and had a normal pregnancy, labor, and birth. However, the baby, though nice and pink at birth with a good heart rate, was not breathing well. The baby was resuscitated by the midwife and rushed to the hospital.