SOB joins SBM – Shines a Light on Home Birth et al.

Dr. Amy Tuteur is to Rikki Lake as PZ Myers is to Ray Comfort. She’s a pit bull that feeds on helpless soy milk drinking, granola crunching, natural home-birth hippies. Hey, those are my friends (and family) she’s eviscerating with evidence-based arguments!!

Dr. Tuteur is a Harvard educated OBGYN who knows her way around a birth canal. She’s currently a full-time Mom and a part-time blogger at the Skeptical OB blog. She also recently joined the ranks at our favorite blog of skeptically-minded doctors, Science-Based Medicine.

She breaks right out of the gate with two articles on home birthing and c-sections. For those familiar with Dr. Tuteur, the information will not be new, but Science-Based Medicine will bring her argument to a wider audience. Considering that she’s substantially shifted my understanding of the issue, I think she deserves to be heard.

At the Dragoncon parenting panel, I mentioned that my wife and I compromised on the birth of our daughter Sasha. My wife wanted a “natural” labor & delivery, and I wanted it at the hospital because I believed, without statistical evidence at the time,  that hospitals would be safer. Then, Skeptrack panelist Daniel Loxton piped in that he and his wife had a home birth because he had looked into the research and decided that home birth was just as safe as hospital birth. It made me shrink a bit to be corrected by a respected professional skeptic, but I still stand by my conclusion that hospitals are ultimately more safe.

I’m pretty sure that Daniel lives in Canada, which might make the difference, but Dr. Amy Tuteur would say that the statistics point to a much different conclusion in America, citing this chart showing that Direct Entry Midwives (home birth) have twice the mortality rate as hospital births…

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36 Responses to SOB joins SBM – Shines a Light on Home Birth et al.

  1. Julie says:

    SBM is really asking for it. Amy gets a lot of angry, angry commenters. Even posting links to her on my blog brings them out of the woodwork. I really like what she has to say, but I guess she’s also piped up about gay marriage and single moms, posting studies that both are somehow not as good for kids. But even though I can’t agree with her opinions (and I just don’t buy her evidence) about those subjects, that doesn’t gainsay a lot of her writing for me.

    • Alexis says:

      Agreed. I like a lot of her information but her presentation is awful. She also tends to attack negative commenters as being too stupid to understand what she has to say. Alternatively, she ignores points that don’t fit into her box. I think she’s also compromised by refusing to acknowledge issues with OB/GYN–if you back her into a corner she generally defends it. If she criticizes an aspect of obstetrics, that’s all right; but if a non-OB does it, she switches sides. I really wish SBM hadn’t picked her up; if she tries her usual tactics with the commenters there, it’s going to be a train wreck.

  2. Jan Andrea says:

    I think it boils down to picking the right provider. There are hospitals in my area with sky-high c-section rates and poor outcomes, and you couldn’t pry me into one of those. I had three (safe) homebirths with a DEM, but you’d better believe I looked at all her statistics (and those of the other midwives available to me) before I made any decisions.

    I also do think the statistics can be misleading. Look at the numbers. There are nearly 200 times as many CNM and MD attended births listed compared to the DEMs; therefore (unless it’s simply too late at night and I am misapplying statistics), any one incident of mortality in the DEM group has a greater effect on the mortality rate as a whole.

    Are there no statistics more recent than 2003/2004 to be had, by the way? This seems a very narrow window to me.

    • philosodad says:

      I think that given the number of births (over 23 thousand) there’s no particular reason to think that the numbers are skewed. That’s a large sample. And while one death has a greater effect on the mortality rate as a whole, you still need to cut the number of deaths in half in order to reach the MD level. So to mistrust the analysis is to say that you have reason to believe that there are 13/14 cases in the mix that are there because of sampling error. I just don’t know that that’s a reasonable argument to make. I suppose you could compare the midwife group to several similar sized samples of the MD group, but if the deaths are evenly spaced in the MD group, it won’t change the outcome.

    • Ticktock says:

      Dr. Tuteur claims that there are more recent data that back up the previous, but she doesn’t provide it in her article on SBM.

  3. Jan Andrea says:

    I should clarify that my midwife is, as required by my state, a certified professional midwife, which is a more rigorous process than just an apprenticeship. She also trained in the Netherlands, where homebirths are the norm, and I was always very comfortable with her competency.

    • Ticktock says:

      It sounds like she might be a CNM (certified nurse midwife); they’re given better training in other countries.

    • Squillo says:

      Actually, you can get a CPM credential with only an apprenticeship and no formal, accredited training. NARM, the organization that credentials CPMs, will credential CPMs through a “portfolio evaluation process” and exam. The ACNM has recently come out with a statement against federal recognition of CPMs who have been credentialed through PEP, rather than through completion of an accredited midwifery program (in addition to an apprenticeship and exam.)

      That said, if your midwife was Dutch-trained, her training is likely roughly equivalent to that of a CNM.

      • Jan Andrea says:

        In NH, CPMs are required to have accredited training. It’s a rigorous process; you can’t just walk in off the street having watched “A Baby Story” and expect to get credentialed.

      • Squillo says:

        The only formal educational requirements I could find for NH midwives are pretty basic, and do not include the completion of an accredited midwifery program:

        # Have completed high school or its equivalent
        # Complete one college-level course in human anatomy and physiology, or pass a college-level equivalency program or credit by exam
        # Neonatal Resuscitation program (NRP) certification
        # Adult and infant/child CPR certification issued by either the American Heart Association or the American Red Cross

        The NHCM–granted by the NH Midwifery Council, is a separate credential from the CPM–granted by NARM–but doesn’t seem to require any additional education.

  4. philosodad says:

    Just one more reason that Daniel Loxton is officially my least favorite public skeptic.

    On the aggregate, home birth might be just as safe as hospital birth. However, let’s say that something goes badly wrong. This may not happen often enough to be statistically significant, but lets say that it does happen to you. Where do you want to be?

    Unless you can demonstrate that there are exactly zero situations in which you which are going to have significantly different outcomes at home and at a hospital, there is a significant difference between them. Because you aren’t making a decision for statistical babies, you’re making a decision for specific ones.

  5. Honestly, the part of this post that struck me the most is how you and your wife compromised on your daughter’s birth. I normally respect your opinions and have absolutely no problem that I generally disagree with your point of view. I like hearing from the other side on most matters and you are very balanced in the way you approach issues, so I continue reading. But to compromise on your wife’s birth. She wanted natural and you didn’t so she was in a hospital. That doesn’t sound like compromise that sounds like she did what you wanted and hoped to have a natural birth in a hospital. In the United States an intervention free (which is how I define natural) birth is increasingly rare. And why would you put your wife’s emotional connection to HER birth in the hands of a hospital, because it made YOU feel better and safer. I think you are underestimating the importance of a birth experience to the mother. I am not saying it is unimportant to the father, but you will NEVER know what it is like to birth and you should never put your feelings about birth above the birthing woman’s. The baby can not have feelings about its birth, a woman will permanently remember the way she felt during and after her birth. Regardless of what you and your statistics have to say about birth, your wife should have the final say and it shouldn’t be a compromise. Sorry to go on a tirade, its just men that want to make deciding factors about birth are taking the only thing women have that is solely theirs, the ability to birth. That empowering wonderful beautiful part of womanhood should remain in the hands of birthing women, no matter how well-intentioned male participants may be.

    • philosodad says:

      “And why would you put your wife’s emotional connection to HER birth in the hands of a hospital, because it made YOU feel better and safer.”

      Because her emotional connection to the BABIES birth is not as important to me as the safety of the baby. It’s ticktock’s right as a father to have a say in matters that affect his children, and to make birth all about the mother completely ignores the health and welfare of the most important person at the birth.

  6. Ticktock says:

    I understand your concerns, but I believe decisions within the marriage should be negotiated, especially when the safety of the child is involved. My concern for the baby’s safety was greater than her desire for a home birth. Her intention to have a drug-free birth was greater than my ambivalence.

    My wife was unlike you in the way that she approached birth. She looked at it as something for us to share. I was very involved, attended the Bradley natural birth classes, and acted as her advocate in the hospital.

    It should also be said that we lived in a small one-bedroom apartment when Sasha was born. Having a home birth was impractical. She didn’t need much convincing to have labor and delivery at a hospital because we didn’t even have a better choice.

    Sasha’s birth worked out perfectly fine without intervention because we were prepared. The thing that pisses off my wife is that she had to go back to work four weeks after the birth of our second child, but she tells me to thank you anyway.

  7. Julie says:

    Clarissa, I have to disagree. The feelings of the mother are not as important as the safety of the baby. And birth should be a discussion between the two parents (if there are two parents involved), not an experience that the mother gets possessive about.

    I had a scheduled c-section, because my son was very large, and I had no signs of labor, and we were quite late. I didn’t dilate or efface, and the baby didn’t lower at all. But mostly, his head size was off the charts (and remains so to this day).

    But my water broke the day of the c-section. We discussed as a family whether to try labor or go ahead with the c-section. As far as I was concerned, my husband had equal input in this decision. There were certain risks to the baby, but I did want to try the labor. But as soon as my husband said that he would feel more comfortable if we went ahead with the c-section (and this was my doctor’s advice as well), I went with that decision.

    The most important person at the birth is the baby. Since that day, I’ve learned more about what can happen to babies in the same situation ours was in. While things could have gone well, I’ve actually met a mother who had the exact same (I mean, really ridiculously close) birth as me, and she now has a son with serious cerebral palsy. He did not enough oxygen on the way out, because his head was too big. That mother wishes she could go back to that day and have a c-section. Her boy will live with a disability caused by birth his entire life.

    How can my experience be worth that risk to my baby?

  8. To be clear, our baby was born in a hospital here in Canada. (My wife’s labour went long, and our plans changed.)

    Our initial choice of a home birth was personal, but the numbers we saw made that personal decision seem reasonable enough: for uncomplicated pregnancies, the risks appeared similar for home birth and hospital deliveries.

    This assessment was actually not inconsistent with the numbers Dr. Tuteur cites. The key difference here is between relative and absolute risk.

    In terms of absolute risk, our conclusion as expectant parents was that both options were very safe — far over 99% safe in both cases — and we made a personal decision with that in mind.

    Public health arguments are more complicated. With large enough numbers, small differences in absolute risk add up.

    • Ticktock says:

      Fair enough. Thanks for your comment, Daniel.

    • Cheryl Hebert says:

      (this is Daniel Loxton’s wife)

      I might add a couple of important details to our story. Our decision to attempt a homebirth also took into account that:

      1 – our midwife was a Registered Nurse (with over 30 years of labour and delivery experience),

      2 – we live almost next door to the hospital.

      (I can guarantee that Daniel would not have agreed to attempt the homebirth with it any other way…)

  9. badrescher says:

    Part of making an informed decision is determining the practical significance of findings. Yes, there is evidence that home births carry a higher risk than hospital births. However, statistically significant differences are not always practically significant, even when risk is involved. Not all evidence should be weighed equally.

    We don’t choose hospitals or midwives at random. A 3:1 risk ratio given such extremely large sample sizes and rather small effect sizes should carry little weight in such a decision, IMO.

    We should continue to discuss and assess the various risks involved with these types of decisions, but it is important to keep in mind the relative strength of evidence and risk. There are a 100 other issues which are much more one-sided in what the evidence suggests is best. Vaccines, for example…

    • Jan Andrea says:

      Very well said. We chose homebirth because of the hospitals in our area and their c-section rates, plus (anecdotal, I know) stories from friends who had delivered there. But if anything had gone wrong, we were 5 minutes from the nearest one, and would have been able to call ahead so that any necessary aid would be waiting for us on our arrival. I would not have been comfortable with a homebirth if, for example, we’d had a good birth center nearby but no good hospital, or if I had been high risk at all, or if I did not have a great deal of trust in my midwife’s training and competence.

    • philosodad says:

      Actually, the evidence is overwhelmingly one sided in this case: if you seriously need emergency care, and you aren’t already in a hospital, you are pretty much screwed. 5 (minimum) extra minutes without oxygen is a lifetime of complications for a baby. There is no ambiguity in the data.

      So, practically speaking, the question is whether you are comfortable giving birth without a net or not. The only reason I can think of for going home birth would be if you were supremely confident that nothing was going to go wrong. Possibly, such confidence is justified in the typical birth.

      But the idea that home birth is “just as safe” is a false impression brought about by the relative safety of giving birth in general.

      • Jan Andrea says:

        What hospitals are you familiar with that could have a c-section done, let alone ready, in five minutes? Unless the surgeon is scrubbed in and waiting in the ER, all prepped for surgery, it’s going to take more than 5 minutes. If it’s O2 for the mom, midwives carry that. Not to mention, it’s a very rare complication that is so sudden that 5 minutes is all you have. Good midwives are trained to recognize difficulties as they crop up, and a competent one will transfer you as soon as that’s visible. If you’re down to 5 minutes, your midwife has missed something major.

        Mine was thinking of transferring me when my second was born, because the placenta was taking its time detaching. Of course, it was only about 30 minutes after the birth, which is perfectly well within normal limits, and it delivered on its own about 10 minutes after that. I wasn’t bleeding unduly, nor was I experiencing any other problems; but she (like a good midwife) wished to err on the side of caution.

      • badrescher says:

        I did not say the data were ambiguous or that the evidence pointed to “just as safe”. Evidence that clearly points to one side does not mean that the difference is large. If there are 999 black marbles in a bowl and 1000 white, there are CLEARLY more white than black. However, I would not bet my life’s savings on drawing a white marble at random.

        Practical significance refers to the extent to which a statistically significant difference matters in real-world application. In this case, it may be an important finding for public health (large samples), but insignificant in regard to individual risk/choice, especially when risk factors (such as quality of care) can be controlled.

        For example, men score higher on math and science tests than women. Therefore, we should ensure that only men are appointed heads of organizations like the NSF, right? OR, we could recognize that the differences between men and women in this area are not practically significant and control the risk factors (i.e., check references).

      • philosodad says:

        @badrescher: what you said was that the data was more one sided in a hundred other cases. It is not.

        And as I pointed out before, and will again: the relative safety of a midwife versus a hospital is absolutely relevant to individuals. The quality of care is better at a hospital. That is a risk factor. An individual can control it. They can choose to ignore it in the belief–largely justified–that complications are very rare. But only if they are comfortable accepting a vastly higher risk of losing the baby should complications occur.

        @Jan Andrea

        My hospital is located in the same fantasy world where a woman, in the midst of giving birth, could be transferred out the front door in 5 minutes, much less to a nearby hospital.

        My point was that the time spent getting to the hospital is time lost, and that time might not be insignificant. You were betting on no complications, and reassuring yourself that proximity to a hospital would matter. I submit that your bet was a reasonable one to make (complications being rare especially in candidates for home birth) but that your emergency plan was not one.

      • badrescher says:

        “what you said was that the data was more one sided in a hundred other cases. It is not.”

        I think it is. The difference is in the statement you are trying to support. If you are attempting to support the statement:

        “Without controlling for other factors (i.e., averaging across providers, locations, underlying conditions, age & education of the mother, method of delivery, and so on and so on) hospital births are safer than home births.”
        … well, then, you’ve got me.

        However, if anyone is making a decision about their birth experience without considering any other factors,then IMO they shouldn’t be having children at all… I’m sure you’ll agree ;)

        The quality of care at some hospitals is better than one would get from some home birthing professionals. The opposite is also true. It is clear from the evidence, however (I’ve analyzed the data myself; it is readily available as the Tuteur stated) that the differences in mean quality are small and variances of both distributions large, making the differences between them not practically significant for most situations. If all other factors are equal, the choice is clear. That is rarely the case.

        Just for the record – I would never choose home birth myself. Just not my style…

    • philosodad says:

      @badrescher

      I am not trying to support the statement you think I am trying to support. This is the statement I am trying to support: “In the unlikely event that something goes wrong, you are unambiguously better off at a hospital.”

      It is clear from an even cursory reading of anything that I have written on this that the statement you are making is not what I am trying to support.

      This is not in doubt or questionable, and there are not a hundred other cases that are more clear cut.

      As I said: “The quality of care is better at a hospital. That is a risk factor. An individual can control it. They can choose to ignore it in the belief–largely justified–that complications are very rare. But only if they are comfortable accepting a vastly higher risk of losing the baby should complications occur.”

      That has nothing to do, in any way, with ignoring risk factors. You are constructing a straw man–at best–of my actual argument.

      • badrescher says:

        I did not construct a straw man and I frankly resent the accusation and your suggestion that I am the one missing the point.

        You criticized the choice of home births based on evidence that hospital births are safer. My comment about practical significance applies to that criticism and nothing else.

        You refuted my comment using hypothetical anecdotes of specific cases in which only one factor matters, whereas the data discussed in the SBM post are very, very general and averaged across many other factors, which is exactly the point I made and defended.

        This is the statement I am trying to support: “In the unlikely event that something goes wrong, you are unambiguously better off at a hospital.”

        I had no intention of arguing this point and I don’t doubt that it is likely true, but you have presented NO evidence to support this statement thus far. The CDC data do not provide information that would allow you or anyone else to determine the effects of complications at birth and anecdotes, “what if” statements, and “it’s a no-brainer” are not evidence.

      • philosodad says:

        “The CDC data do not provide information that would allow you or anyone else to determine the effects of complications at birth”

        —————

        Actually, yes, they do. That’s exactly the nature of the evidence that we’re discussing: in the event of complications, where are the better outcomes? And my point is now and has always been that the better outcomes are at a hospital.

        You are making the point that complications are uncommon. I have acknowledged your point repeatedly. I just don’t think that the fact that complications are uncommon completely negates the fact that in the event of complications, a pregnant woman is better off in a hospital than at home.

        Your original point was that safety should not carry much weight, because complications are unlikely. I think that is a reckless attitude to take.

  10. Emilia says:

    Amy Tuteur is “rational” when the evidence in question fits her personal views. For example, she dismisses evidence (endorsed by psychological associations) that same-sex parenting is no more or less damaging than opposite-sex parenting. I suspect that because she has by her own admission two children with serious psychiatric problems she sees happy same-sex and single parent family and gets jealous and wants to make herself feel “superior” to them. In vulgar terms, she’s proud without a pot to piss in.

    With regard to home birth, I don’t have any personal stake in it either way. I didn’t choose it for myself, and even if I met the criteria for it, I probably wouldn’t choose it anyway (I don’t make the grade at this point, because I’ve had a cesarean section) – though I wish there were more trained nurse midwives working in Canadian hospitals. However, judging from literature I’ve read, it seems home birth can be as safe as hospital births if a.) the woman is not at high risk of complications (ex. breech position of the fetus, post-date), b.) the birth attendant is trained (ex. certified nurse midwife) and c.) if anything does go wrong, there is quick transportation to a hospital. Again, this wouldn’t cause me to give birth at home even if I met these qualifications, but I am forced to concede that home birth can be safe in certain situations, just as even though I’m 100%heterosexual I have to admit that lesbians can be as good (and in some studies, even better) parents as heterosexual women.

  11. Simon says:

    Thought I might chime in here as my girlfriend had a home birth a week ago, and initially I was somewhat sceptical as to whether it was as safe an option as having the baby in hospital. We live in the UK and the official line we were given by both the NHS and the NCT (National Childbirth Trust) was that home births are as safe as hospital births for women who are not ‘at risk.’ There are a fair few checks and balances in place to ensure that the woman is in the ‘low risk’ category and as such many home birthers end up in hospital anyway.

    Although my thinking was still, well, ‘bottom line is that hospital births are probably safer’ I decided that given NHS advice and the reassurance of our midwives and, most importantly, the wishes of my girlfriend, I wouldn’t interfere. Even if something did go wrong an ambulance could still get us to hospital in 15 minutes, just as if something had gone wrong in hospital it’s not like the woman can instantly go into surgery anyway.

    The midwives who came to our house were both NHS trained, and went well above and beyond their remit in the service they provided. What struck me the most was that because we were at home my girlfriend was much more relaxed than she (probably) would have been in a more medicalised environment and as such her adrenaline levels stayed low. I’m no expert here, but as we were told higher adrenaline levels interfere with the body’s production of endorphins which in turns raises the chances for medical interventions, which in turns raises the chances for a c-section – correct me if i’m wrong on this.

    To cut a long story short the baby was born without any interventions beyond gas and air, and there was no tearing afterwards. Importantly it was a happy experience for all involved and whatever risk was taken by having a home birth *seemed* outweighed by its tremendous physical and mental benefits. Also if you don’t want a home birth but the mother does, then discuss the situation but ffs let the mother decide! Having seen what they go through it’s really not a man’s place to dictate how a woman should experience birth.

    I’m about as far away from an anti-science, anti-vaccination type idiot as you can get, and i’m certainly not anti-hospital birth. However I thought I’d throw my own anecdote onto the pile just for the record.

  12. Emilia says:

    Julie, you say the most important person in the birth is the baby. Do you remember the case of Angela Carder, a woman in Washington, DC who had terminal cancer and was forced to have a cesarean to “save” her baby? She ended up dying as a result of the operation (and the child ultimately died as well; she was too premature). Who was the most important person in this story, Angela Carder or her fetus/baby?

  13. Ramona says:

    I’m not sure what the source is if the statistics quoted above are. It’s easy to lie with statistics so make sure the studies are done well, and read the critiques of them by others. There are some solid scientific studies that show that homebirth with qualified professionals for low-risk women are as safe as hospital births, and have fewer interventions and undesirable features/morbidity.
    http://mana.org/hbref.html

    On the surface it seems that giving birth in a hospital right by emergency equipment and the possibility of cesarean section would be safer than giving birth even next door to a hospital. Unfortunately there are many other factors that enter into the equation.

    1. As well stated above by Jan Andrea,
    “What hospitals are you familiar with that could have a c-section done, let alone ready, in five minutes? … If it’s O2 for the mom, midwives carry that. Not to mention, it’s a very rare complication that is so sudden that 5 minutes is all you have. Good midwives are trained to recognize difficulties as they crop up, and a competent one will transfer you as soon as that’s visible. If you’re down to 5 minutes, your midwife has missed something major.”
    Often the midwife can call ahead so the hospital can prepare for the situation that she is transferring for. As for super time-sensitive complications such as shoulder dystocia and babies who need resuscitation, qualified midwives are trained to respond to these emergencies.

    2. Hospitals tend to overuse interventions, which adds risks that weren’t there in the first place.

    3. Even in a good hospital a patient usually can’t predict what staff they will get, and the quality can vary quite a bit. With a homebirth midwife, you know who you’re getting. Of course all parents should research the qualifications/references of their care providers no matter what birth setting they choose.

    4. As noted above by Simon, fear increases adrenaline levels which increases complications. Some women feel more comfortable in the hospital but many feel more fearful. Also, emotionally negative experiences do have a “real” physical effects, such as higher rates of post-partum depression leading to decreased ability to care for one’s baby properly and safely.

    5. Parents have rights. Homebirth parents rarely choose homebirth just for “touchy-feely” reasons. Generally they research the issue much more thoroughly than those who choose hospital birth, and they choose homebirth because they feel it is a better option overall for them, including safety-wise. There are many issues on which I disagree with other people’s parenting choices (including the extreme example of abortion), but they still have the right to make them. And there is good scientific support for homebirth with a trained attendant; it’s not a reckless choice but one carefully considered.

    ~~~~~
    The ideal situation would be having enough midwives to provide homebirth services to all parents who wanted it, with good, supportive coordination with all hospital staff and respect on both sides.

    A couple of good books on the subject:

    Goer, Henci; Obstetric Myths Vs. Research Realities: A Guide to the Medical Literature.

    Enkin, Murry; Guide to Effective Care in Pregnancy and Childbirth [Cochrane Review of all relevant research; written in medicalese. Available as free download at childbirthconnection.org]

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