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Israel Gale's Homebirth Safety Information

I have received a number of inquiries in connection with my offer (in the Midwives and Infant Deaths thread) to provide references to scientific literature showing that midwife-attended births are less risky than doctor-attended births.

I am not personally knowledgeable in this field, but I was the instigator of a (regrettably contentious) thread on "Home vs. Hospital" in the early days of sci.med.midwifery where references to this literature were posted.

The official sci.med.midwifery archives no longer go back that far, but I found the relevant information by browsing the "Home vs. Hospital" thread of sci.med.midwiferry on DejaNews.

Here are the excerpts I thought were relevant. I have given the e-mail addresses of the posters so you can search for the full postings on DejaNews if you want.

Israel Gale - gale@hpc.pko.dec.com

NanC RN 

The Public Citizen's Research Group [(202) 588-7734] published two books that both contain many references to the safety, cost savings, and satisfaction of care provided by Nurse-Midwives. One of these is: "Encouraging the Use of Nurse-Midwives: A Report for Policy Makers" this one . . . has been successfully presented to many legislators and hospital administrators for use in convincing them of the benefits, safety, etc. of CNM's. The second one is: "Delivering a Better Childbirth Experience: A Consumers Guide to Nurse-Midwifery"- this one is meant primarily for those considering a CNM for care.

Patrice Bobier 

There is an excellent article in the BIRTH Journal, 22:2, June 1995 entitled Midwifery Care and Medical Complications: the Role of Risk Screening that analyzes data from birth certificates for 147,293 midwife-attended births, breaking it down to home, hospital, CNM or other midwife.

diorio@netaxis.com (Sharon DiOrio)

Kitzinger, Sheila, Homebirth: "The Essential Guide To Giving Birth Outside Of The Hospital," (1991) Dorling Kindersley p. 43

The Netherlands 1986 Perinatal Mortality Rate By Birth Attendant And Place

                                                  Perinatal Mortality
   Attendant         Place       # of Births      per 1,000 births
   Obstetrician      Hospital    83,351           18.9
   General Pract.    Home        21,653           4.5
   Midwives          Hospital    34,874           2.1
   Midwives          Home        44,676           1.0

Statistics of perinatal mortality rates according to risk score of mother

Perinatal mortality rate per 1,000 births Risk Hospital General Practitioner Unit/Home Very Low 8.0 3.9 Low 17.9 5.2 Moderate 32.2 3.8 High 53.2 15.5 Very High 162.6 133.3 # of Births 11,000 5,200

Tew M. (1981) "Effects of scientific obstetrics on perinatal mortality," Health and Social Services Journal, 91, 444-446

armidwife@aol.com (AR midwife)

The study Tew did showed that the same practitioner had better stats at home than at the hospital.

Sgulie@ix.netcom.com

Rather a large number of studies have been done on this. To date, the studies show, without exception, a lower rate of mortality and morbidity for mothers and infants in all risk categories with home birth.

armidwife@aol.com (AR midwife)

There are lots of studies comparing the statistics of the different birth attendants. LOTS OF THEM. I would post the bibliography if you are interested, but it is very long. The really best study is a book by Marjorie Tew entitled Safer Childbirth?

Here in Arkansas the OBs have a 8.3/1000 infant mortality while the CNMs have a 6.8 and the LDEMs have a 4.0.

Julia Bertschinger 

I note that Deb Phillips, LDEM responded to you and recommended Tew's 1990 book Safer Childbirth? I second that recommendation. Given your interest in comparing the safety of midwife-attended births in hospital with midwife-attended births in homes, I also recommend a 1991 article by Tew and Damstra-Wijmenga (discussed below).

Research statistician Tew, a member of the British Royal Society of Medicine's Forum on Maternity and the Newborn, found that the British maternity system is run by obstetricians who "withhold and pervert knowledge in order to maintain public ignorance and delusion." [Tew M. Safer childbirth? A critical history of maternity care. London: Chapman and Hall 1990.]

Tew also found that British obstetricians have for decades engaged in, "the false use of statistics to support a system that was actually harming its intended beneficiaries." [1990]

In 1991, British research statistician Tew teamed up with Dutch physician Sonya Damstra-Wijmenga, M.D. to publish statistics demonstrating that independent, non-nurse Dutch midwives, practicing in homes and hospitals, were associated with 10 times fewer perinatal deaths than Dutch obstetricians. Tew and Damstra-Wijmenga noted that high risk patient selection bias could only account for a small part of the obstetricians' ten-fold greater perinatal mortality rate.

Wrote Tew and Damstra-Wijmenga: "Though unlikely, excess risk might conceivably have been high enough to account for threefold or, at a stretch a fourfold discrepancy between obstetricians' and midwives' perinatal mortality rates; it could not have been nearly high enough to account for the ten fold discrepancy actually experienced...[The obstetricians'] higher perinatal mortality rates at all identified grades of predicted risk...support the...hypothesis...that obstetricians' care actually provokes and adds to the dangers." [Tew M, Damstra-Wijmenga SMI. Safest birth attendants: recent Dutch evidence. Midwifery 1991;7:55-65. SMI Damstra-Wijmenga, M.D., van Ketwich Verschuurlaan 5, 9721SB Groningen, HOLLAND; Marjorie Tew, 121 Bramcote Ln, Wollaton, Nottingham NG8 2NJ ENGLAND]

In part as a result of Tew and Damstra-Wijmenga's work, a Select Committee of the British government was formed to survey the world literature regarding maternity care. The Select Committee discovered (and reported in 1992) that women have been getting biased information:

"[A] 'medical model of care' should no longer drive the maternity service and women should be given unbiased information...including the option, previously denied to them, of having their babies at home..." [House of Commons Select Health Committee, Second Report 1992. Quoted in Department of Health (Britain). Changing Childbirth HMSO Publications Centre, P.O. Box 276, London, SW8 5DT.]

In a recent telephone conversation with Sheila Kitzinger of Great Britain, Ms. Kitzinger noted that the Cochrane Center is finding that Tew and Damstra-Wijmenga "compared apples and oranges." In other words, according to Ms. Kitzinger, the Cochrane Center has determined that one cannot conclude from Tew and Damstra-Wijmenga's 1991 study that homebirth is safer than hospital birth.

I noted in reply to Ms. Kitzinger that if Dutch midwives are routinely offering sacroiliac motion - and if Dutch obstetricians are not - it doesn't matter, from the perspective of sacroiliac motion, whether the findings of Tew and Damstra-Wijmenga indicate that homebirth per se is safer. Some factor (or factors) caused babies to die 10X more frequently under obstetric care. Routine obstetric use of semi-recumbency (jamming tailbones up to an inch into fetal skulls) may be causing more than "asymptomatic" brain bleeds. . . . [detailed discussion of the hazards and politics of the semi-sitting birth position follows]

armidwife@aol.com (AR midwife)

The best study which is the one Marjorie Tew did shows the stats for the same midwives delivering in the hospital or at home. The study covers the socio-economic variance that would seem to affect birth outcomes. And Marjorie was not trying to prove home birth safer. She is a professor of epidemiology who made an assignment to her class to study the mortality statistics and was so amazed to see home birth come up as the safer modality that she published those stats. In the Netherlands they report births more accurately and with more detail as to place of origin and thus the study is a good representation of the effects of location of birth.

mue@gsf.de (Bernhard Muenzer):

 

The type of study you're asking for is impossible. I'll keep looking if you're interested though.

A woman choosing a home delivery usually does so because she feels more secure at home than in a hospital - and vice versa. Forcing a woman to give birth in a surrounding where she does not feel comfortable (or should I say "at home" ;-) will make it harder for her to relax and increase the risk of prolonged labour or other complications.

One solution to this problem might be the comparison not of two samples women choosing different places to give birth, but of two countries.

One might be Holland with a home birth rate of over 30%, and the other one might be Germany, which has a low home birth rate, but requires a midwife to be present at each birth.

But again, there are some statistical problems with this approach.

From Sharon's numbers it seems that in Holland a birth can be attended by an obstetrician, a general practitioner or a midwife, while in Germany only a midwife is allowed to attend a birth alone. Sharon's table shows that the choice of practitioner seems to influence the perinatal mortality significantly, so this might add another bias to the data.

Another problem is that "perinatal mortality" is not as well-defined as it appears. It may be that a child of 500 g that died shortly after a birth is registered in the statistics under perinatal mortality, but in another country (or in another year), children with a weight below 2000 g might be only counted as abortus.

In Germany, this weight limit has been lowered from 2000 g to 500 g lately. This takes into account the progress in neonatology and allows parents to officially name and bury their small stillborn babies. However, this legal change suddenly gave an increase in the official perinatal mortality rate.

Furthermore, different countries may have different time limits as to when a death is still counted as perinatal mortality and when it is counted as infant mortality. A study comparing data from two countries must find a way to eliminate this kind of error.

The reason I am elaborating on these points is that a study of the kind I described has been published in Germany about a year ago.

Unfortunately, I did not keep the references for this paper, and I am not able to locate the discussions that took place in the aftermath of the publication (I am glad I don't post this on alt.folklore.urban - they'd flame me to hell for this negligence). It is possible that it can be found in the November 1994 issue of the "Deutsche Hebammenzeitung" (at least this issue is missing in my wife's archive).

This study compared Germany to Holland (or possibly Denmark) and came to the result that Germany had a lower perinatal mortality - due to the lower rate of home deliveries. However, the author had been caught of having manipulated the data in a way I hinted at above.

For example, he had chosen to compare different years for both countries. For Germany, he selected a year when the 2000 g weight limit was still in effect (which virtually lowered the mortality rate), and compared this to data using a lower weight limit - which biased the data favourably for Germany.

There were protests coming from many places, including high officials at the WHO, and attempts by the same author at fudging other studies were also exposed. However, I have not heard that the medical journal published a retraction, and the study (or rather the author's interpretation of the results) keep appearing in the oddest places, like my mother-in-law's TV magazine ("Scientists have proved that ...").

never trust a statistic you haven't forged yourself

Todd Gastaldo [gastaldo@gte.net]

Subject: Is safety dangerous? ACNM schizophrenia about homebirth...

. . . After studying homebirth in depth, the British government concluded:

 

[We] must draw the conclusion that the policy of encouraging all women to give birth in hospitals cannot be justified on grounds of safety...[I]t is no longer acceptable that the pattern of maternity care provision should be driven by presumptions about the applicability of a medical model of care based upon unproven assertions...Hospitals are not the appropriate place to care for healthy women...We recommend that the Department of Health vigorously pursue the establishment of best practice models of team midwifery care...

[A] "medical model of care" should no longer drive the maternity service and women should be given unbiased information...including the option, previously denied to them, of having their babies at home...

[House of Commons Select Health Committee, Second Report 1992. Quoted in Department of Health (Britain). Changing Childbirth HMSO Publications Centre, P.O. Box 276, London, SW8 5DT. Thanks to Trudy Saunders (071-972-2000 ext. 4155), Assistant to Baroness Julia Cumberlidge, Parliamentary Under Secretary of State for Health, in the office of Virginia Bottomley, Parliamentary Secretary of State for Health, Wellington House, 133-155 Waterloo Road, London SE1 8UG.]

In 1995, ACNM devoted an entire issue of the Journal of Nurse-Midwifery to a home study course on how to do homebirths. [The home study program on home birth. JNM (Nov/Dec)1995;40(6)entire issue] . . . .

In response to the Nov/Dec 1995 ACNM homebirth home study course, nurse-midwifery professor Janice Keller Kvale, PhD, CNM of Case Western University stated, "for too long, home birth has not been an accepted option within North American health care systems." Dr. Kvale conveniently failed to mention that CNMs unscientifically/indirectly took part in the obstetricians "homebirth is child abuse" libel. [Kvale JK. Letter. JNM (May/Jun)1996;41(3):227] . . . .

. . . Kvale [1996] noted in her letter to JNM, "Too many of the interventions commonly used in hospital labor and delivery suites are based on tradition or peer acceptance and not on sound science...Randomized controlled trials and other research methods are necessary to test ways to make hospital birth safer and less costly, just as they are needed to test the safety of [techniques used during -TDG] birth in the home."