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The home birth debate.

A September 2010 meta-analysis involving 12 studies, conducted by Joseph R. Wax and colleagues, added fuel to the ongoing debate about the safety of home birth. The authors made the controversial decision to look at neonatal mortality, defined as death within 28 days, in addition to perinatal mortality and maternal interventions and complications surrounding delivery. None of the studies in the meta-analysis were designed to determine neonatal mortality. In addition, the meta-analysis's definition for "perinatal"--"stillbirth of at least 20 weeks or 500 g or death of liveborn within 28 days of birth"--overlaps the definition for "neonatal." Using all 12 studies, the perinatal death rate between planned home births and planned hospital births was statistically the same. Perinatal mortality is the primary monitor for delivery safety. Neonatal deaths, however, showed a "three fold increase" in planned home births: 23 babies (without a congenital deformity) out of 15,633 planned home births died within 28 days compared to 14 out of 31,999 planned hospital births. The authors suggest that this increased neonatal mortality is due to "decreased obstetric intervention" in the form of ultrasound, electronic fetal heart rate monitoring, fetal acid-base assessment, labor induction, and cesarean delivery. The meta-analysis offers no evidence to support this supposition, nor does it consider confounding socioeconomic and environmental factors such as poverty that could contribute to death in the first month of life.

Not surprisingly, proponents of home birth and midwifery criticized the quality of this meta-analysis. According to the Coalition for improving Maternity Services (CIMS) chair Michelle Kendell, "'CIMS found that the authors of the study included confounding data, such as outdated and low-quality studies, low-risk and high-risk mothers, babies born preterm, babies unintentionally born at home, births attended by unqualified providers and data from birth certificates that researchers have found to be notoriously inaccurate.'" Critics of the meta-analysis also questioned the exclusion of a 2005 study by Johnson and Daviss, "the only high-quality study of planned homebirths in the U.S." The Johnson and Daviss study "showed excellent health outcomes for infants and their mothers when attended by certified professional midwives."

Gill Gyte and Mary Newburn at the UK's National Childbirth Trust and Alison Macfarlane, a professor of prenatal health at London's City University, reviewed the studies used to determine neonatal mortality. They found that "not all the included studies used the same definitions and some gave no definition of perinatal or neonatal deaths." In addition, the meta-analysis identifies six studies used to determine the neonatal mortality rate, but Table 3 says that seven were used. Byte, Newburn, and Macfarlane say that "careful scrutiny of the primary research papers that have been included in the meta-analysis suggests that there are eight studies that contribute to [perinatal mortality] and-with some overlap and some differences-eight studies that contribute to [neonatal mortality] ... missing data and absence of clear definitions in some papers means that further work is needed to ascertain for sure which studies contribute data for each of the two different outcomes measures. ... "In addition, most studies used to determine mortality rates did not adjust for confounding risk factors. The study that contributed the most data to mortality was retrospective (the least reliable type of study) based on birth registry data (Pang JWY et al. Outcomes of planned home births in Washington State: 1989-1996. Obstet Gynecol. 2002;100:253-259).

Gyte, Newburn, and Macfarlane also criticize the meta-analysis for its failure to report quality assessments for the included studies and its failure to discuss the limitations of the small numbers involved in the neonatal analysis. Despite these flaws, the American College of Obstetricians and Gynecologists, a strong opponent of home births, labeled the Wax meta-analysis "Editors Choice." Ironically, ACOG opposes home birth because of "safety concerns and lack of rigorous scientific study."

The slight (and questionable) increase in neonatal deaths is the only negative finding against planned home birth in this meta-analysis. Wax and colleagues report that women who had a planned home birth had fewer medical interventions (e.g., epidurals, electronic fetal heart monitoring, episiotomy, and cesarean) and fewer complications (i.e., infections, third-degree or greater lacerations, hemorrhages, and retained placentas). Home birth babies were less likely to be premature, have a low birth weight, or need assisted newborn ventilation.

In her response to the Wax meta-analysis, Melissa Cheyney, assistant professor of medical anthropology at Oregon State University, wrote: "In Oregon, where we have both licensed and unlicensed midwives working in home and in birth center settings, research has shown deep mistrust between doctors [who believe that only hospital deliveries are safe] and some midwives. ... Such studies [like this meta-analysis] only deepen this mistrust and have the potential to increase hostility during encounters when midwives and their clients have to seek hospital care for complications. The end result is a system that can be detrimental to women and their babies because of the impaired ability to communicate. ..." She points out that 99% of US women give birth in hospitals, but the US perinatal death rate is 6.3 deaths per 1000 babies-one of the highest rates among developed countries. In comparison, the Netherlands has 4.73 deaths per 1000 even though one-third of all deliveries are midwife-assisted home births. "There is something to be learned from the centuries-old traditions of midwifery," Cheyney writes, "and I believe that if doctors and midwives, including those who work in the home setting, could be willing to learn from and respect one another, women and babies in our country would benefit. After all, we are all working for the same end result: a happy and healthy mother and baby. ..."

Cheyney M. Why home births are worth considering [online article]. Huffington Post. September 9, 2010. www.huffingtonpost.com/melissa-cheyney/post_812_b_709215.html. Accessed January 10, 2011.

Coalition for Improving Maternity services. CIMS respond to the publication of an extremely skewed study on the safety of homebirth [press release]. July 9. 2010. Available at: www.scribd.com/doc/34274333/CIMS-Responds-to-Skewed-Article-on-Homebirth. Accessed January 12, 2011.

Gyte G, Newburn M, Macfarlane A. Critique of a meta-analysis by Wax and colleagues which has claimed that there is a three-times greater risk of neonatal death among babies without congenital anomalies planned to be born at home. Available at; www.scribd.com/doc/34065092/Critique-of-a-meta-analysis-by-Wax. Accessed January 31, 2011.

Wax JR, Lucas FL, Lamont M, Pinette MG, Cartin A, Blackstone J. Maternal and newborn outcomes in planned home birth vs planned hospital births: a metaanalsis. Am J Obstet Gynecol. September 2010. Available at: www.ajog.org/article/S0002-9378(10)00671-x. Accessed January 12, 2011.

briefed by Jule Klotter

jule@townsendletter.com
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Title Annotation:Shorts
Author:Klotter, Jule
Publication:Townsend Letter
Article Type:Report
Geographic Code:1USA
Date:Apr 1, 2011
Words:1099
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