Haven’t we seen this guy before?

The research discussed at length above is similar to what The American College of Obstetricians and Gynecologists and others have been presenting for many, many years and which I personally heard presented at a Conference for Maternal and Child Health Workers and Educators in the 1970's at The University of New Hampshire's New England Center

The OB/GYN physician who was presenting to the entire group gave similar statistics and "cautions" to those noted above and which, I knew - as a home birth advocate and CEA Child Birth Educator - were based on ALL out of hospital births from birth certificates. However, the way he spoke made them seem to represent planned home births with well trained midwives or knowledgeable others in attendance.

When he quoted this study, I knew that most people in the room would know nothing about it nor it's inappropriate use of statistics and so I raised my hand to question the presenter about his knowledge of it. I was ignored for a bit before I simply stood up and asked him if he knew that this study included ALL the babies that were born outside of a hospital WITH NO TRAINED MIDWIFE OR other health care worker in attendance because of no other choice due to financial limitations or on the street due to a fast labor, in a car or taxi on the way to the hospital or in it's parking lot etc.

He just looked at me blandly, made no response at all, and continued speaking as though I did not exist...

Now in the year 2013 I ASK.... WHEN will this type of blatant misrepresentation of facts finally be acknowledged and ended?

Now that you are Director of Research Wendy. Can you please release the data regarding the neonatal deaths of Homebirth that MANA has refused to release under Melissa's tenor? It would be nice for American women to know when weighing the risks of choosing where to deliver. We know Homebirth offers fewer interventions, but what are the neonatals deaths rates.

"...for low-risk women with a skilled midwife in attendance..."

Could MANA please provide specifics regarding what qualifies pregnant women as 'low-risk' as well as the definition of a 'skilled' midwife?

Thank you.

The debate over data and outcomes regarding homebirth seems to be never ending. How should we interpret numbers? What is our obliglation about honestly conveying risks to expecting mothers and families? The truth is that MANA has the ability to help shed light on these concerns by releasing all of its data, including neonatal mortality statistics. If the numbers are in line with claims that homebirth is truly as safe as hospital births, won't that be reassuring to the many women considering homebirth as an option? And won't that silence the critics, especially those that feel MANA is deliberately hiding alarming statistics? Conversely, if the numbers are worrisome, does that not open the dialogue about what needs to happen to make homebirth safer? Do women not deserve options for birth that all work towards the goal of maternal and neonatal health and well being? I hope that in the coming months, MANA will respond appropriately, and like any professional organization should, will fully disclose ALL of its data. It's just the right thing to do.

From the study abstract (emphasis mine):

Home births (relative risk [RR], 10.55) and births in free-standing birth centers (RR, 3.56) attended by midwives had a significantly higher risk of a 5-minute Apgar score of 0 (P < .0001) than hospital births attended by physicians or midwives. Home births (RR, 3.80) and births in freestanding birth centers attended by midwives (RR, 1.88) had a significantly higher risk of neonatal seizures or serious neurologic dysfunction (P < .0001) than hospital births attended by physicians or midwives.

So I'm not sure your objection about intended place of birth means much. Or are you saying that unattended home births that result in low Apgars are mistakenly being listed as midwife-attended? Who's recording the Apgars for these unintended home births?

Thank you, MANA, for this thoughtful analysis of the recent news coverage. It is helpful as I grow in my own understanding of home birth research and also as I talk with families. Your voice and perspective are appreciated!

I'm glad to see someone raise sensible questions regarding methodology and interpretation (and causation versus correlation) in this study. It's alarming that AJOG would release information based on such little evidence as a birth certificate. I'm also not seeing any information about the size of the sample used--just a period of years??

Hi,
You say: "First, it is vitally important to note that this study did not actually examine rates of stillbirth, but rather 5-minute Apgar scores. The press release is completely misleading and inaccurate on this point." Where does it go wrong? The definition of a stillbirth recommended by WHO is "a baby born with no signs of life at or after 28 weeks' gestation." An Aogar score of zero defines a baby with no signs of life. How do you define a stillbirth and what is the difference to an Apgar of zero?

The heart of Gordon's piece is this:

"What we know about using information drawn from birth certificates is that they are pretty good for capturing information about things like mother’s age and whether she is carrying twins. They are not very accurate when it comes to rare outcomes like very low Apgar scores, seizures, or deaths (Northam & Knapp, 2006)."

But the Northam & Knapp article, SPECIFICALLY says the OPPOSITE!

"Birthweight, Apgar score, and delivery method agreed 91.9% to 100%. The high-percent agreement supports the reliability of those variables …"

So the heart of Gordon’s argument is completely untrue. And Gordon referenced the mistruth with a citation that showed the opposite of what she claimed it showed.

Do you plan to correct that misinformation?

Thanks so much for this post, Wendy and MANA. The new blog looks wonderful and I look forward to more thoughtful and important content. It's disappointing to see that birth certificate research to address the question of safety of homebirth is still finding its way through peer review. I thought the field was holding itself to higher scientific standards. I am very much looking forward to seeing the first papers from the MANA stats project. Thanks again for all you do!

Thank you Wendy Gordon (and MANA) for teasing apart this information. I'm grateful to have this concise rebuttal to reference in discussions about home birth safety.

Thank you Wendy and MANA for beginning to address the issues posed in this study. It is important that we remember that this study, and future studies of homebirth will be looked at with many critical eyes. As a midwife, I know how difficult it is to rely on birth certificates for information. In much of our country, planned place of birth is not asked, only the actual place of birth. Some areas ask for very specific information on neonatal ourcomes, but many of those are not know until well after the birth. I am unclear how an accurate accountlng of the outcomes could be garnered from birth certificates alone.

"The result: while a small percentage of intended home birth deaths are wrongly attributed to hospital deaths using birth certificate data, a much larger percentage of home births with no injury to mother or baby are wrongly attributed to hospitals as well."

But there were 200 times as many hospital births as homebirths, so even if a massive proportion of homebirth attempts ended in a live hospital birth, it would have NO IMPACT on the overall rate of hospital birth death or hospital live birth. However, since the number of women attempting homebirth is only 1/200th of that attempting hospital birth, and since death is a relatively rare outcome, leaving a few deaths out of the homebirth group would make a very big difference in the homebirth death rate.

In other words, the hospital birth death rate is basically unaffected by the liveborn homebirth transfers, while the homebirth death rate is considerably lowered by removing the deaths that occurred after transfer.

The study shows that homebirth increases the stillbirth rate by nearly 1000% and that's an underestimate of the true rate.

I know those who want to take a woman's choice of where to birth away can be a strong force and often paid off by medical lobbies. Thank you for your diligent work in fact checking yet another garbage-quality anti-home birth piece and thank you for enduring this often unbearable comment thread. Those of us who know home birth know the truth behind the safety and know what's at stake by the erroneous publications trying to mislead women who simply want to make informed choices about their planned place of birth. Thank you for all of your hard work in this process!

So, the researchers ONLY collected apgar scores at 5 minutes? While they were spending time and money processing this VAST amount of data, they didn't collect immediate apgar scores or followup scores? Why?

And who was reporting the apgar score, and who was filling out the paperwork? Who says the score was X at 5 minutes? The parents? Midwives? Doctors?

Why does this entire study seem like a load of crap?

I wish there were this much scrutiny on hospital statistics, or the lack thereof! So many commenters here seem really upset about the accuracy of home birth data. The simple answer is, don't have a home birth if you don't think it's safe. In the meantime, I'd love to see the same level of criticism aimed at the places where 99% of women give birth, where we know there are lots and lots and lots of problems.

So I am completely confused. HOW is it that researchers, using birth certificate APGAR scores, regardless of 1 or 5 minutes, determine ANYTHING and conclude ANYTHING about STILLBIRTHS at home OR in hospital? STILLBORN BABIES ARE DEAD at birth and therefore are NOT recorded on a BIRTH CERTIFICATE at all. And since a stillborn baby was never alive at birth, no signs of life were recorded, no death certificate is issued either. STILLBIRTHS are RARELY captured accurately in Vital Records and this this "research" is profoundly flawed regardless of place of birth!

But what about the other birth data? And who is filing these certificates? Who is assessing these five minute Apgars of O, and what are the 10 minute scores? When a 5 min Apgar of less than 7 is recorded on my State's electronic birth cert filing program, it automatically requires a 10 minute score. This score would only be absent on a legal certification in my state if the infant never had another Apgar assessment, in which case s/he would be dead, and a death certificate would be filed instead. There are also sections asking if the infant was transferred within 24 hours and if the infant died after a live birth. To the extent that it is possible to infer anything from birth certificate data, a well done study might have included this information in their analysis, as well as looking at reported abnormal conditions of the newborn, congenital anomalies, characteristics of labor, and maternal morbidity, all of which can be found right there on the same certificate. That the researchers had access to this data is proven by the inclusion of the relative incidence of "seizures or serious neurological dysfunction" in their data set. What is interesting to me is that none of the other "abnormal conditions of the newborn" included on all US birth certificates are even discussed in this study. Are we to assume that these seizures and neurological dysfunctions happened in a vacuum, unrelated to assisted ventilation, admission to NICU, or suspected neonatal infection? Who made these assessments of neurological dysfunction, anyway? And are these a subset of the neonates with the dubious Apgar scores, an entirely different subset with their own outcomes, or what? I just don't understand why Chervenak, et al chose to focus particularly on seizures and 5 minute Apgar scores, and how they believe this data,extracted willy-nilly from a larger set of statistical information, can really be useful as "prognostic data for future outcomes."
I do understand that the researchers in this case have an obvious bias, and are merely furthering the stated agenda of ACOG to aggressively hold their ground against the "recrudescence" of home birth by cherry picking the data, but all it really proves is that birth certificate statistics are an easily exploited but ultimately unreliable source for that data, as was already proven by the notorious and embarrassingly flawed Pang study, which no one (except midwives,haha) wants to talk about anymore. Come on ACOG, you can do better than that.