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New Studies Confirm Safety of Home Birth With Midwives in the U.S.

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Posted by Midwives Alliance on January 30th, 2014

by Geradine Simkins, CNM, MSN, Executive Director, Midwives Alliance of North America

In today’s peer-reviewed Journal of Midwifery & Women’s Health (JMWH), a landmark study** confirms that among low-risk women, planned home births result in low rates of interventions without an increase in adverse outcomes for mothers and babies.

This study, which examines nearly 17,000 courses of midwife-led care, is the largest analysis of planned home birth in the U.S. ever published.

The results of this study, and those of its companion article about the development of the MANA Stats registry, confirm the safety and overwhelmingly positive health benefits for low-risk mothers and babies who choose to birth at home with a midwife. At every step of the way, midwives are providing excellent care. This study enables families, providers and policymakers to have a transparent look at the risks and benefits of planned home birth as well as the health benefits of normal physiologic birth.

Of particular note is a cesarean rate of 5.2%, a remarkably low rate when compared to the U.S. national average of 31% for full-term pregnancies. When we consider the well-known health consequences of a cesarean -- not to mention the exponentially higher costs -- this study brings a fresh reminder of the benefits of midwife-led care outside of our overburdened hospital system.

Home birth mothers had much lower rates of interventions in labor. While some interventions are necessary for the safety and health of the mother or baby, many are overused, are lacking scientific evidence of benefit, and even carry their own risks. Cautious and judicious use of intervention results in healthier outcomes and easier recovery, and this is an area in which midwives excel. Women who planned a home birth had fewer episiotomies, pitocin for labor augmentation, and epidurals.

Most importantly, their babies were born healthy and safe. Ninety-seven percent of babies were carried to full-term, they weighed an average of eight pounds at birth, and nearly 98% were being breastfed at the six-week postpartum visit with their midwife. Only 1% of babies required transfer to the hospital after birth, most for non-urgent conditions. Babies born to low-risk mothers had no higher risk of death in labor or the first few weeks of life than those in comparable studies of similarly low-risk pregnancies. 

Importantly, this study also sheds light on factors that may increase risk. These findings are consistent with other research on pregnancy complications, but the numbers of these pregnancies were low in the MANA Stats dataset, making it impossible to make clear recommendations. This article from Citizens for Midwifery contains important information to share with families who are contemplating their birth options and weighing their individual risks and benefits.

This study is critically important at a time when many deeply-flawed and misleading studies about home birth have been receiving media attention. Previous studies have relied on birth certificate data, which only capture the final place of birth (regardless of where a woman intended to give birth). The MANA Stats dataset is based on the gold standard -- the medical record. As a result, this study provides a much-needed look at the outcomes of women who intended to give birth at home (regardless of whether they ultimately transferred to hospital care). The MANA Stats data reflects not only the outcomes of mothers and babies who birthed at home, but also includes those who transferred to the hospital during a planned home birth, resolving a common concern about home birth data.

This study adds to the large and growing body of research that has found that planned home birth with a midwife is not only safe for babies and mothers with low-risk pregnancies, but results in health and cost benefits that reach far beyond one pregnancy. We invite you to share this news in your communities, and join the conversation on our Facebook page, Twitter, and Pinterest

We are grateful to the ongoing support of the Foundation for the Advancement of Midwifery, which has been a major funder of the MANA Statistics Project.

** Note added 12:33 EST when the issue was published:

Dr. Combs, thank you for your

Dr. Combs, thank you for your comment. As mentioned above, the outcomes from the Cheyney et al study are not able to be compared to U.S. hospital rates, because the hospital data is not fully reported. The CDC reports neonatal deaths, which are quite comparable to the neonatal rates reported in the Cheyney et al study, but the CDC does not report intrapartum death rates for hospitals. Some have made the convenient assumption that no babies ever die during labor in any hospital setting, but there is no data whatsoever to support that assertion. We look forward to a time when hospital data is transparent in this regard, and we applaud the work of The Joint Commission in their efforts to make this happen. But at this time, it is not possible to assemble a similar low-risk cohort from national vital statistics data for general comparison purposes.

Intrapartum Death

This worries me.

Although I am not an OB, I have been caring for people's health for 30 years. Your study reports 1.30/1000 intrapartum deaths. If James Sasek's report of 0.38/1000 intrapartum deaths in low risk hospital births is correct, that is a huge difference, and for me, a deal breaker. I would also say that your reporting of home birth "without an increase in adverse outcomes for mothers and babies", is then unsubstantiated.
0.38/1000 vs 1.3 deaths/1000 may seem trivial, unless that 0.92/1000 is your baby.

Don't believe everything you read on the internet

James Sasek's report of 0.38/1000 comes from "Dr. Amy's" misleading analysis. She squeezed out an early neonatal death rate of 0.38 from the CDC Wonder database and compared it to MANA's intrapartum plus early plus late neonatal death rate. It's these sort of antics that make it really confusing for families to know what to believe. And given the latest press release from Grunebaum and Chervenak about a presentation they're making at a conference - not about an actual study that had been peer reviewed or published, mind you, but a conference presentation - conveniently timed to coincide with MANA's research... well, it's starting to be really obvious that there's more to this debate than providing clear information for mothers and families to make good decisions for themselves. Shameful.

Data Source

I apologize for not citing my osurce. It is via Dr. Amy at SkeptialOB and the data is from the CDC Wonder Database of hospital low risk births for the same time period. The published study here compares data with out dated studies and data sets from other countries with different regulatory environments for homebirths. They authors do not even mention why it doesn't consider the CDC data from the same time period to be comparable though it's publicly available and current. I think that's a huge miss.

Thanks for taking the time to review this comment. I'm grateful the MANA data has been published.

Please see our response to

Please see our response to your similar question above regarding why it is not possible to make full comparisons with hospital data.  The Cheyney et al study does not compare to “out dated studies” - all of the other well-designed studies mentioned in the comparisons were published between 2009 and 2013, with the exception of the one prior study on CPM-attended home births in North America which was published in 2005. Several of the comparison studies were indeed conducted in other countries, and it is well-acknowledged that they have varying health care systems and integration of midwives within them. For the most part, those maternity care systems would probably measure up better than the U.S., and it is reassuring that the Cheyney et al outcomes with regard to intrapartum and/or neonatal death were similar, despite the lack of integration of midwives into the U.S. system.

Hospital intrapartum mortality rate is .1 - .3/1000?

I read that Judith Rooks stated the intrapartum mortality rate for hospitals is 0.1-0.3/1000 for low and high risk. Is that true? She is a CNM.

It's true that she said it, I

It's true that she said it, I saw her show up on another blog and say it, but apparently it's under dispute. Her numbers seem to be pulled from a bunch of other countries (Wales, Scotland, Canada) and one US state (Missouri). This seems to lend credence to the idea that national numbers are not available in the US or she wouldn't have had to stretch so far to dig something up. At least Judith Rooks is not saying that it's zero anymore, it's too bad that Dr. Amy held her up to be such a hero for that and then she changed her story. Awkward! But as far as I can tell, we still don't know what the intrapartum mortality rate is for US hospitals. That's crazy. Why don't we have this information?

I see. This is all very

I see. This is all very confusing. What about neonatal mortality rates for US hospitals? Are they accurate through the wonder data base?

Homebirth low risk women

This agrees with all of the studies perfomred in the UK and subsequent good outcomes for low risk pregnancies/births. In fact in my 2 birth centres one co-located and one freestanding I have just published our 3 year data analysis. IN over 4050 births all low risk our caesarean section rate is less than 3.5% with less than 1% of babies admitted to the NICU department for treatment. No fatalities of either mothers or babies and breastfeeding rates of over 98%. THe majority of births are either laboured in water or have all 3 stages of labour in water meaning that actual births in water is near 75% again with no contamination or readmissions for babies or mothers.
I am no statistician but I am confident in midiwfery led care and I would say that as our model is being replicated in more than 10 oethr units throughout England we have a good safety and outcome record.
If anyone would like to see a copy of my report please go to https://www.swbh.nhs.uk/services/maternity/

Why aren't you addressing the concerns?

There are several comments here that concern me. I keep checking back to see if anyone from MANA has responded. But no one has. Instead the comments have just been rearranged so that the comments giving praise are now at the top and the newer comments addressing concerns are now at the bottom. MANA, please address these questions. I need answers.

All comments have been

All comments have been responded to; please let us know if there are still specific questions that you feel have not been adequately addressed.

Unbiased Analysis of the MANA Study

Brooke Orosz, PhD, a professor of statistics, has offered an unbiased analysis of the MANA study. MANA, what is your response?

"In other words, the expected number of deaths from causes other than congenital anomalies was at most 12, and the actual number of deaths was 35 (44 with anomalies included). It is clear that home birth substantially increases the risk of neonatal death and of intrapartum death."

"15.5% of the mothers in the MANA STATS group experienced a postpartum hemorrhage over 500ml, with 4.8% losing over 1000mL. Nationally, only 3.3% of vaginal births resulted in a postpartum hemorrhage exceeding 500 ml, with few exceeding 1000ml, and only 2% of cesarian births involved a PPH exceeding 1000 ml.(3) These nationwide numbers do NOT control for preexisting maternal risk factors, which are more prevalent in the hospital group as previously noted. Clearly, home birth substantially increases the risk of PPH."

"The mothers in the MANA STATS cohort experienced fewer childbirth interventions than comparable-risk women giving birth in the hospital.

However, the rate of intrapartum stillbirth or neonatal death was considerably higher, and the difference was particularly alarming among high-risk subgroups such as breech and VBAC. The incidence of low APGAR was significantly higher and may have been much higher. The risk of postpartum hemorrhage was substantially higher.

Women considering home birth should be aware of these risks. Furthermore, the risk of death is increased for babies in breech presentations, and infants born to first-time mothers or mothers with a prior history of cesarian birth."

http://tinyurl.com/n5v5tc3

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